Provider Demographics
NPI:1780727875
Name:KANG, ANNE C (OD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:C
Last Name:KANG
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 1:29495 MEADOW GLEN WAY W
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-6518
Mailing Address - Country:US
Mailing Address - Phone:858-774-5111
Mailing Address - Fax:
Practice Address - Street 1:1481 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3613
Practice Address - Country:US
Practice Address - Phone:619-477-2159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11668T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0116680Medicaid
CAWOP11668BMedicare ID - Type Unspecified
CAWOP11668CMedicare ID - Type Unspecified
CASD0116680Medicaid