Healthcare Provider Details

I. General information

NPI: 1871678557
Provider Name (Legal Business Name): KING YUE WONG OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 SEVENTH STREET SUITE #201
SANTA MONICA CA
90401-2638
US

IV. Provider business mailing address

316 SOUTH KENTER AVE
LOS ANGELES CA
90049-4022
US

V. Phone/Fax

Practice location:
  • Phone: 310-450-9998
  • 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: DR. KING YUE WONG
Title or Position: DIRECTOR OWNER
Credential: OD
Phone: 310-471-9618