Provider Demographics
NPI:1427041961
Name:KWONG, PATRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:KWONG
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 1:655 MEDICAL CENTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2751
Mailing Address - Country:US
Mailing Address - Phone:503-581-5287
Mailing Address - Fax:
Practice Address - Street 1:655 MEDICAL CENTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2751
Practice Address - Country:US
Practice Address - Phone:503-581-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI3470152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500650154Medicaid
OR500650154Medicaid
IL046009504Medicaid