MEDICARE: DR. BEN HAROLD WONG JR. O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD00001974	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275609463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BEN HAROLD WONG JR. O.D.

Provider Business Mailing Address
First Line	:	1940 BLACK LAKE BLVD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5651
Country	:	US
Telephone Number	:	360-570-1780
Fax Number	:	360-570-1801

Provider Business Practice Location Address
First Line	:	1940 BLACK LAKE BLVD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5651
Country	:	US
Telephone Number	:	360-570-1780
Fax Number	:	360-570-1801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	04/21/2008

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