Provider Demographics
NPI:1265786842
Name:DR. KALLI LEUNG, O.D., PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DR. KALLI LEUNG, O.D., PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KALLI
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-895-2020
Mailing Address - Street 1:1371 E 14TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4728
Mailing Address - Country:US
Mailing Address - Phone:510-895-2020
Mailing Address - Fax:510-895-2393
Practice Address - Street 1:1371 E 14TH ST
Practice Address - Street 2:STE A
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4728
Practice Address - Country:US
Practice Address - Phone:510-895-2020
Practice Address - Fax:510-895-2393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13609TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ756AMedicare PIN