Healthcare Provider Details

I. General information

NPI: 1316618986
Provider Name (Legal Business Name): TESTIN TAI JUN KWONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 BROADWAY
MILLBRAE CA
94030-2509
US

IV. Provider business mailing address

2167 19TH AVE
SAN FRANCISCO CA
94116-1802
US

V. Phone/Fax

Practice location:
  • Phone: 650-697-2475
  • Fax:
Mailing address:
  • Phone: 415-490-7409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: