Provider Demographics
NPI:1366798415
Name:KWEON, KELLEY D (OD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:D
Last Name:KWEON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:121 HIGHWAY 332 W STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566
Mailing Address - Country:US
Mailing Address - Phone:979-480-9424
Mailing Address - Fax:979-480-9426
Practice Address - Street 1:121 HIGHWAY 332 W STE 100
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566
Practice Address - Country:US
Practice Address - Phone:979-480-9424
Practice Address - Fax:979-480-9426
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7999TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist