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General NPI Number Information
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NPI Number | 1184002172
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Entity Type | Organization
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Legal Business Name | MICHAEL WANG, OD, A PROFESSIONAL OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 05/11/2015
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Last Update Date | 05/11/2015
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Provider Practice Location Address
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Address Line | 10066 PACIFIC HEIGHTS BLVD SUITE 112
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City | SAN DIEGO
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State | CA
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Zip | 92121-4211
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Country | US
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Telephone | 858-526-0890
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Fax | 858-526-0899
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Provider Business Mailing Address
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Address Line | 10066 PACIFIC HEIGHTS BLVD SUITE 112
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City | SAN DIEGO
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State | CA
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Zip | 92121-4211
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Country | US
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Telephone | 858-526-0890
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Fax | 858-526-0899
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL WANG
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Credential | O. D.
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Telephone | 858-526-0890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT15191
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License Number State | CA
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