Healthcare Provider Details

I. General information

NPI: 1508202201
Provider Name (Legal Business Name): MICHELLE WONG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38707 STIVERS ST SUITE B
FREMONT CA
94536-5337
US

IV. Provider business mailing address

38707 STIVERS ST SUITE B
FREMONT CA
94536-5337
US

V. Phone/Fax

Practice location:
  • Phone: 510-794-0660
  • Fax: 510-793-5044
Mailing address:
  • Phone: 510-794-0660
  • Fax: 510-793-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: