MEDICARE: GORDON MILES WONG OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8140T	CA

General Provider Information

NPI Number	:	1417949942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON MILES WONG OD

Provider Business Mailing Address
First Line	:	1712 SPYGLASS RD
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94954-5700
Country	:	US
Telephone Number	:	707-778-1048
Fax Number	:	707-778-0113

Provider Business Practice Location Address
First Line	:	66 E WASHINGTON ST
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-3165
Country	:	US
Telephone Number	:	707-778-1048
Fax Number	:	707-778-0113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	07/08/2007

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