Healthcare Provider Details

I. General information

NPI: 1710137708
Provider Name (Legal Business Name): DR. CAROLYN WONG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11540 SANTA MONICA BLVD SUITE 202
LOS ANGELES CA
90025-7905
US

IV. Provider business mailing address

11540 SANTA MONICA BLVD SUITE 202
LOS ANGELES CA
90025-7905
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-5464
  • Fax:
Mailing address:
  • Phone: 310-473-5464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7450T
License Number StateCA

VIII. Authorized Official

Name: CAROLYN M WONG
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 310-473-5464