Provider Demographics
NPI:1508210139
Name:KANG, AMRITA (OD)
Entity Type:Individual
Prefix:
First Name:AMRITA
Middle Name:
Last Name:KANG
Suffix:
Gender:F
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:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-0358
Mailing Address - Country:US
Mailing Address - Phone:503-462-3811
Mailing Address - Fax:503-630-3529
Practice Address - Street 1:405 NE MAIN ST
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-8528
Practice Address - Country:US
Practice Address - Phone:503-630-3528
Practice Address - Fax:503-630-3529
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR4313ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program