Provider Demographics
NPI:1316061237
Name:KWON, ELAINE SEONOG (OD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:SEONOG
Last Name:KWON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:SEONOG
Other - Last Name:YOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2380 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-1621
Mailing Address - Country:US
Mailing Address - Phone:415-566-8199
Mailing Address - Fax:415-566-8198
Practice Address - Street 1:2380 IRVING ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-1621
Practice Address - Country:US
Practice Address - Phone:415-566-8199
Practice Address - Fax:415-566-8198
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11788T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72-1584284OtherFEIN
CA16524OtherMES
CA16524OtherMES
CA72-1584284OtherFEIN