Provider Demographics
NPI:1134265218
Name:KWONG, SUSAN SOSUN (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SOSUN
Last Name:KWONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 S LUCILE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-2258
Mailing Address - Country:US
Mailing Address - Phone:206-280-8781
Mailing Address - Fax:
Practice Address - Street 1:12310 NE 8TH ST STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3185
Practice Address - Country:US
Practice Address - Phone:425-455-0001
Practice Address - Fax:425-462-7387
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12906T152W00000X
WAOD00004010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD00004010OtherOPTOMETRY LICENSE NUMBER
CAOPT 12906TOtherOPTOMETRY LICENSE NUMBER
CAWOP12906AMedicare PIN