Provider Demographics
NPI:1871629923
Name:LU, KEVIN QUOC (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:QUOC
Last Name:LU
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 1:9197 CENTRAL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1616
Mailing Address - Country:US
Mailing Address - Phone:909-626-1412
Mailing Address - Fax:
Practice Address - Street 1:9197 CENTRAL AVE STE D
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1616
Practice Address - Country:US
Practice Address - Phone:909-626-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10715T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871629923Medicaid
CA1871629923Medicaid