MEDICARE: CRYSTAL WONG O.D., P.C.

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	046009664	IL

General Provider Information

NPI Number	:	1285913830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL WONG O.D., P.C.

Provider Business Mailing Address
First Line	:	2349 S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2013
Country	:	US
Telephone Number	:	312-808-1893
Fax Number	:

Provider Business Practice Location Address
First Line	:	2349 S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2013
Country	:	US
Telephone Number	:	312-808-1893
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CRYSTAL S WONG
Credential	:	O.D.
Telephone Number	:	312-808-1893

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	08/15/2011

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