MEDICARE: DR. KING YUE WONG OD

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	OPT12461TPA	CA
2	152WL0500X	Low Vision Rehabilitation Optometrist	OPT12461TPA	CA
3	152WP0200X	Pediatric Optometrist	OPT12461TPA	CA

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
2	1871678557	OTHER	CA	NPI # (ORGANIZATION & GROUP)
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336471440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KING YUE WONG OD

Provider Business Mailing Address
First Line	:	316 S KENTER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-4022
Country	:	US
Telephone Number	:	310-471-9618
Fax Number	:	310-450-8580

Provider Business Practice Location Address
First Line	:	1431 7TH ST
Second Line	:	SUITE # 201
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2637
Country	:	US
Telephone Number	:	310-395-2106
Fax Number	:	310-450-8580

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

Provider Enumeration Date	:	02/01/2010
Last Update Date	:	02/01/2010

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Directions to “ DR. KING YUE WONG OD” Practice Location

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