Healthcare Provider Details

I. General information

NPI: 1770554057
Provider Name (Legal Business Name): GW EYE ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7841 FAY AVENUE
LA JOLLA CA
92037
US

IV. Provider business mailing address

7841 FAY AVENUE
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-4699
  • Fax: 858-454-3797
Mailing address:
  • Phone: 858-454-4699
  • Fax: 858-454-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT9832
License Number StateCA

VIII. Authorized Official

Name: MR. GORDON G WONG
Title or Position: PRESIDENT
Credential: OD
Phone: 858-454-4699