Provider Demographics
NPI:1497949267
Name:KONGSAKUL, ANDY KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:KEITH
Last Name:KONGSAKUL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ANDY
Other - Middle Name:KEITH
Other - Last Name:KONGSAKUL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:19636 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3647
Mailing Address - Country:US
Mailing Address - Phone:818-774-2020
Mailing Address - Fax:818-774-2021
Practice Address - Street 1:19636 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3647
Practice Address - Country:US
Practice Address - Phone:818-774-2020
Practice Address - Fax:818-774-2021
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13639T152W00000X
NYTUV007213-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649400920Medicaid
NY02965231Medicaid