MEDICARE: JEFFREY JOSEPH KONG OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10356	TX
2	152W00000X	Optometrist	34996TLG	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10356	OTHER	TX	STATE LICENSE
3	34996TLG	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1730750985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY JOSEPH KONG OD

Provider Business Mailing Address
First Line	:	1515 W HILLVIEW CT
Second Line	:
City	:	GILROY
State	:	CA
Zip	:	95020-3753
Country	:	US
Telephone Number	:	408-310-1271
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 MINOR HALL MC-2020
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94720-2020
Country	:	US
Telephone Number	:	510-642-2020
Fax Number	:	510-642-8012

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	08/06/2022

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