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General NPI Number Information
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NPI Number | 1760403430
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Entity Type | Organization
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Legal Business Name | MIKE V. WONG, O.D. A PROFESSIONAL CORP.
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 09/11/2009
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Provider Practice Location Address
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Address Line | 80 N LAKE AVE SUITE 102
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City | PASADENA
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State | CA
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Zip | 91101-5626
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Country | US
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Telephone | 626-356-8088
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Fax |
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Provider Business Mailing Address
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Address Line | 80 N LAKE AVE SUITE 102
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City | PASADENA
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State | CA
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Zip | 91101-5626
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Country | US
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Telephone | 626-356-8088
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MIKE V. WONG
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Credential | O.D.
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Telephone | 626-356-8088
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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 | 10566T
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License Number State | CA
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