Healthcare Provider Details

I. General information

NPI: 1831881895
Provider Name (Legal Business Name): ALEXANDER WONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE FL 3
BOSTON MA
02118-4001
US

IV. Provider business mailing address

850 HARRISON AVE FL 3
BOSTON MA
02118-4001
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4020
  • Fax:
Mailing address:
  • Phone: 617-414-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011770
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5724
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: