Provider Demographics
NPI:1316618986
Name:KWONG, TESTIN TAI JUN (OD)
Entity type:Individual
Prefix:
First Name:TESTIN
Middle Name:TAI JUN
Last Name:KWONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1802
Mailing Address - Country:US
Mailing Address - Phone:415-490-7409
Mailing Address - Fax:
Practice Address - Street 1:305 BROADWAY
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2509
Practice Address - Country:US
Practice Address - Phone:650-697-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist