Provider Demographics
NPI:1760611362
Name:KWON, TIFFANY ANGIE (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANGIE
Last Name:KWON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANGIE
Other - Last Name:LAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2014 CALVARY CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8469
Mailing Address - Country:US
Mailing Address - Phone:909-569-9290
Mailing Address - Fax:
Practice Address - Street 1:2014 CALVARY CIR APT 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8469
Practice Address - Country:US
Practice Address - Phone:909-569-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007421-1152W00000X
VA0618002533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03179962Medicaid
NY03179962Medicaid