Healthcare Provider Details

I. General information

NPI: 1659301364
Provider Name (Legal Business Name): MATTHEW WANG OD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ODYSSEY SUITE 150
IRVINE CA
92618-3186
US

IV. Provider business mailing address

22 ODYSSEY SUITE 150
IRVINE CA
92618-3186
US

V. Phone/Fax

Practice location:
  • Phone: 949-733-3390
  • Fax: 949-461-1461
Mailing address:
  • Phone: 949-733-3390
  • Fax: 949-461-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12376T
License Number StateCA

VIII. Authorized Official

Name: DR. MATTHEW WANG
Title or Position: PRESIDENT
Credential: OD
Phone: 949-733-3390