Provider Demographics
NPI:1679167878
Name:JANG, KYU HWAN (ABO)
Entity Type:Individual
Prefix:
First Name:KYU
Middle Name:HWAN
Last Name:JANG
Suffix:
Gender:M
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S WESTERN AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3042
Mailing Address - Country:US
Mailing Address - Phone:213-389-1001
Mailing Address - Fax:213-389-1002
Practice Address - Street 1:621 S WESTERN AVE STE 214
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-3042
Practice Address - Country:US
Practice Address - Phone:213-389-1001
Practice Address - Fax:213-389-1002
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
162590156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
162590OtherABO