Provider Demographics
NPI:1033296645
Name:TONG, KHANH KRISTINE (OD)
Entity type:Individual
Prefix:
First Name:KHANH
Middle Name:KRISTINE
Last Name:TONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9741 BOLSA AVE
Mailing Address - Street 2:SUITE #115
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6683
Mailing Address - Country:US
Mailing Address - Phone:714-839-9915
Mailing Address - Fax:714-839-9974
Practice Address - Street 1:9741 BOLSA AVE
Practice Address - Street 2:SUITE #115
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6683
Practice Address - Country:US
Practice Address - Phone:714-839-9915
Practice Address - Fax:714-839-9974
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11759T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117590Medicaid
CASD0117590Medicaid