Provider Demographics
NPI:1376863142
Name:KHONG, KATHY (OD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:KHONG
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 1:1300 SW 6TH AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3464
Mailing Address - Country:US
Mailing Address - Phone:971-200-8428
Mailing Address - Fax:971-269-2905
Practice Address - Street 1:1300 SW 6TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3529
Practice Address - Country:US
Practice Address - Phone:971-200-8428
Practice Address - Fax:971-269-2905
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3360ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR32086OtherREGENCE BLUE CROSS BLUE SHIELD
OR500630758Medicaid
ORR157712Medicare PIN