Provider Demographics
NPI:1902155393
Name:KANG, DOO YEON (OD)
Entity Type:Individual
Prefix:
First Name:DOO
Middle Name:YEON
Last Name:KANG
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 1:206 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8907
Mailing Address - Country:US
Mailing Address - Phone:912-537-2020
Mailing Address - Fax:912-537-7935
Practice Address - Street 1:206 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-2020
Practice Address - Fax:912-537-7935
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002744152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135309BMedicaid
GA003135309CMedicaid
GA003135309AMedicaid
GA003135309BMedicaid