Provider Demographics
NPI:1427029123
Name:KWONG, AVON WAI (OD)
Entity Type:Individual
Prefix:DR
First Name:AVON
Middle Name:WAI
Last Name:KWONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AVON
Other - Middle Name:
Other - Last Name:WAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:611 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-4405
Mailing Address - Country:US
Mailing Address - Phone:415-982-0388
Mailing Address - Fax:415-217-7010
Practice Address - Street 1:611 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4405
Practice Address - Country:US
Practice Address - Phone:415-982-0388
Practice Address - Fax:415-217-7010
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9376TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0093760Medicaid
U47939Medicare UPIN
SD0093760Medicare ID - Type Unspecified