Healthcare Provider Details

I. General information

NPI: 1700543196
Provider Name (Legal Business Name): MELISSA SUSAN WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S ATLANTIC BLVD STE A
MONTEREY PARK CA
91754-3872
US

IV. Provider business mailing address

8540 RAVENDALE RD
SAN GABRIEL CA
91775-1122
US

V. Phone/Fax

Practice location:
  • Phone: 626-570-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35866
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number35866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: