Provider Demographics
NPI:1295090579
Name:SULKYUNG NA OPTOMETRY INC
Entity type:Organization
Organization Name:SULKYUNG NA OPTOMETRY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SULKYUNG
Authorized Official - Middle Name:J
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-564-0760
Mailing Address - Street 1:431 E 1ST ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5303
Mailing Address - Country:US
Mailing Address - Phone:714-564-0760
Mailing Address - Fax:714-564-0747
Practice Address - Street 1:431 E 1ST ST STE 4B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5303
Practice Address - Country:US
Practice Address - Phone:714-564-0760
Practice Address - Fax:714-564-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11542T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568551125OtherINDIVIDUAL NPI
CASD0115420Medicaid