Provider Demographics
NPI:1851556021
Name:KONG, JACKY KIN WAI (OD)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:KIN WAI
Last Name:KONG
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 1:1125 COMMONWEALTH AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3207
Mailing Address - Country:US
Mailing Address - Phone:617-818-0476
Mailing Address - Fax:
Practice Address - Street 1:940 COMMONWEALTH AVE
Practice Address - Street 2:BOSTON
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1203
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-27
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4689152W00000X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics