Provider Demographics
NPI:1043210578
Name:WANG, MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ODYSSEY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-733-3390
Mailing Address - Fax:949-461-1461
Practice Address - Street 1:22 ODYSSEY
Practice Address - Street 2:SUITE 150
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-733-3390
Practice Address - Fax:949-461-1461
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12376T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD012376Medicaid
CAU96417Medicare UPIN
CAOP12376Medicare ID - Type Unspecified