Provider Demographics
NPI:1699490060
Name:CHIU, KEVIN KUO-KANG
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:KUO-KANG
Last Name:CHIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 WETHERBY RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1522
Mailing Address - Country:US
Mailing Address - Phone:626-318-8789
Mailing Address - Fax:
Practice Address - Street 1:320 N GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3758
Practice Address - Country:US
Practice Address - Phone:818-254-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist