Healthcare Provider Details

I. General information

NPI: 1063254175
Provider Name (Legal Business Name): YUSTINA CHAEYEON KANG OD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N COURTHOUSE RD
NORTH CHESTERFIELD VA
23236-4062
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 804-858-2020
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003417
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: