Provider Demographics
NPI:1487879227
Name:KONG L CHANG OPTOMETRIST PLLC
Entity type:Organization
Organization Name:KONG L CHANG OPTOMETRIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KONG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-840-5664
Mailing Address - Street 1:5801 N MAY AVE STE 110B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3947
Mailing Address - Country:US
Mailing Address - Phone:405-840-5664
Mailing Address - Fax:405-840-5663
Practice Address - Street 1:5801 N MAY AVE STE 110B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3947
Practice Address - Country:US
Practice Address - Phone:405-840-5664
Practice Address - Fax:405-840-5663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2355152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBLUE CROSS & BLUE SHIELDS
OKU93188Medicare UPIN
OK=========001OtherBLUE CROSS & BLUE SHIELDS