Provider Demographics
NPI:1922088038
Name:KANG, SAM CHADWELL (OD (OPTOMETRIST))
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:CHADWELL
Last Name:KANG
Suffix:
Gender:M
Credentials:OD (OPTOMETRIST)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 29TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-3109
Mailing Address - Country:US
Mailing Address - Phone:319-390-9969
Mailing Address - Fax:
Practice Address - Street 1:3601 29TH AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3109
Practice Address - Country:US
Practice Address - Phone:319-390-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02295152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAWELLMARK 38635OtherOPTOMETRY
IAV04626Medicare UPIN
IAI14989Medicare ID - Type UnspecifiedOPTOMETRY
IAI14989Medicare PIN