Healthcare Provider Details

I. General information

NPI: 1336471440
Provider Name (Legal Business Name): KING YUE WONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 7TH ST SUITE # 201
SANTA MONICA CA
90401-2637
US

IV. Provider business mailing address

316 S KENTER AVE
LOS ANGELES CA
90049-4022
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-2106
  • Fax: 310-450-8580
Mailing address:
  • Phone: 310-471-9618
  • Fax: 310-450-8580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT12461TPA
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPT12461TPA
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT12461TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: