MEDICARE: JONATHAN T WONG OD PC

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	5607TG	TX

General Provider Information

NPI Number	:	1407058605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN T WONG OD PC

Provider Business Mailing Address
First Line	:	12420 FM 1960 RD W
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77065-4809
Country	:	US
Telephone Number	:	832-237-1688
Fax Number	:

Provider Business Practice Location Address
First Line	:	12420 FM 1960 RD W
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77065-4809
Country	:	US
Telephone Number	:	832-237-1688
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JONATHAN T WONG
Credential	:	OD
Telephone Number	:	832-237-1688

Provider Enumeration Date	:	06/01/2007
Last Update Date	:	02/10/2014

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