Basic Information
| Provider Information | |||||||||
| NPI: | 1902155393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANG | ||||||||
| FirstName: | DOO | ||||||||
| MiddleName: | YEON | ||||||||
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| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9125377935 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9125377935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002744 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 003135309B | 05 | GA | MEDICAID | 003135309C | 05 | GA | MEDICAID | 003135309A | 05 | GA | MEDICAID |