Healthcare Provider Details

I. General information

NPI: 1063158137
Provider Name (Legal Business Name): CHRISTOPHER WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246765 N 23RD AVENUE SUITE 110
PHOENIX AZ
85085
US

IV. Provider business mailing address

6501 W MOLLY LN
PHOENIX AZ
85083-6516
US

V. Phone/Fax

Practice location:
  • Phone: 925-998-3444
  • Fax:
Mailing address:
  • Phone: 925-998-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2710
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: