Provider Demographics
NPI:1164506713
Name:KWOK, MICHAEL G (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:KWOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8123 GILROY DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2937
Mailing Address - Country:US
Mailing Address - Phone:443-845-1188
Mailing Address - Fax:540-786-3793
Practice Address - Street 1:440 SPOTSYLVANIA TOWNE CENTRE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-1123
Practice Address - Country:US
Practice Address - Phone:540-786-2272
Practice Address - Fax:540-786-3793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001613152W00000X
MDTA2010152W00000X
DCOP1000135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11643528OtherCAQH
VA1164506713Medicaid
VAF548Medicare PIN