MEDICARE: MITCHEL WONG MD

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	D1873	TX

General Provider Information

NPI Number	:	1659379204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHEL WONG MD

Provider Business Mailing Address
First Line	:	1009 E 40TH ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-4838
Country	:	US
Telephone Number	:	512-454-2020
Fax Number	:	512-454-1681

Provider Business Practice Location Address
First Line	:	1009 E 40TH ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-4838
Country	:	US
Telephone Number	:	512-454-2020
Fax Number	:	512-454-1681

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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