Healthcare Provider Details

I. General information

NPI: 1336201615
Provider Name (Legal Business Name): KEITH YUN KONG WONG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 DALE RD SUITE 300
MODESTO CA
95356-0505
US

IV. Provider business mailing address

1608 LAVENDER LN
MODESTO CA
95355-3771
US

V. Phone/Fax

Practice location:
  • Phone: 209-574-0710
  • Fax: 209-529-9030
Mailing address:
  • Phone: 209-521-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8152T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: