Provider Demographics
NPI:1730750985
Name:KONG, JEFFREY JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:KONG
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 1:1515 W HILLVIEW CT
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3753
Mailing Address - Country:US
Mailing Address - Phone:408-310-1271
Mailing Address - Fax:
Practice Address - Street 1:230 MINOR HALL MC-2020
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2020
Practice Address - Country:US
Practice Address - Phone:510-642-2020
Practice Address - Fax:510-642-8012
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10356152W00000X
CA34996TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX426300601Medicaid
TX10356OtherSTATE LICENSE
CA34996TLGOtherSTATE LICENSE