Healthcare Provider Details

I. General information

NPI: 1346303856
Provider Name (Legal Business Name): JENNIFER ANN WONG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28825 RYAN RD
WARREN MI
48092-4128
US

IV. Provider business mailing address

155 OAKLANE DR
ROCHESTER HILLS MI
48306-3425
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-0470
  • Fax: 586-573-0648
Mailing address:
  • Phone: 248-608-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number4901003737
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: