Provider Demographics
NPI:1922336817
Name:HENRY M KWONG, M.D. A PROF MED CORP
Entity Type:Organization
Organization Name:HENRY M KWONG, M.D. A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KWONG, M.D.
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-367-1247
Mailing Address - Street 1:607 RUE DE BRILLE
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563
Mailing Address - Country:US
Mailing Address - Phone:337-367-1247
Mailing Address - Fax:337-365-7496
Practice Address - Street 1:607 RUE DE BRILLE
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563
Practice Address - Country:US
Practice Address - Phone:337-367-1247
Practice Address - Fax:337-365-7496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENRY M. KWONG, M.D. A PROF MEDICAL CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012632207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1197980Medicaid
LA53636Medicare PIN
LAD62755Medicare UPIN