Healthcare Provider Details

I. General information

NPI: 1447338447
Provider Name (Legal Business Name): GORDON G WONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7841 FAY AVE
LA JOLLA CA
92037-4251
US

IV. Provider business mailing address

7841 FAY AVE
LA JOLLA CA
92037-4251
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 Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number9832T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: