Provider Demographics
NPI:1306824495
Name:KWONG, PETER O (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:O
Last Name:KWONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1815
Mailing Address - Country:US
Mailing Address - Phone:757-452-3480
Mailing Address - Fax:757-452-3482
Practice Address - Street 1:225 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1815
Practice Address - Country:US
Practice Address - Phone:757-452-3480
Practice Address - Fax:757-452-3482
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232710208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
196919OtherANTHEM BC/BS
VA007504284Medicaid
VA245559OtherANTHEM BC BS
VA58060OtherSENTARA HEALTHCARE
VA245559OtherANTHEM BC BS
VA340020148Medicare ID - Type UnspecifiedRAILROAD MEDICARE
VA340000706Medicare ID - Type Unspecified