Provider Demographics
NPI:1962503227
Name:WONG, KATHLEEN R (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:R
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:R
Other - Last Name:SOLUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:201 5TH AVE S
Mailing Address - Street 2:STE 102
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3646
Mailing Address - Country:US
Mailing Address - Phone:425-771-7772
Mailing Address - Fax:425-775-9973
Practice Address - Street 1:402 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3138
Practice Address - Country:US
Practice Address - Phone:425-771-7772
Practice Address - Fax:425-775-9973
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024537Medicaid
WA0149513OtherL&I
WA2024537Medicaid
WAU64970Medicare UPIN