Provider Demographics
NPI:1164787628
Name:WONG, SELENA CONSTANCE (OD)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:CONSTANCE
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:CONSTANCE
Other - Last Name:CHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:STE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2385
Mailing Address - Country:US
Mailing Address - Phone:213-413-7301
Mailing Address - Fax:213-413-7303
Practice Address - Street 1:2619 E COLORADO BLVD STE 150
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-793-4168
Practice Address - Fax:626-793-6256
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002662152W00000X
CA33549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102733683Medicaid
PAOEG002662OtherLICENSE
PA102733683Medicaid