Healthcare Provider Details

I. General information

NPI: 1568950657
Provider Name (Legal Business Name): KEITH MICHAEL WONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18120 BROOKHURST ST STE 19
FOUNTAIN VALLEY CA
92708-6727
US

IV. Provider business mailing address

18120 BROOKHURST ST STE 19
FOUNTAIN VALLEY CA
92708-6727
US

V. Phone/Fax

Practice location:
  • Phone: 949-208-9009
  • Fax:
Mailing address:
  • Phone: 714-508-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100657
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34715
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11124T
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5295
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-OPT-LIC-5171
License Number StateMT
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number011064
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: