Provider Demographics
NPI:1184002172
Name:MICHAEL WANG, OD, A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:MICHAEL WANG, OD, A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:DESIGNER EYES OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:858-526-0890
Mailing Address - Street 1:10066 PACIFIC HEIGHTS BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4211
Mailing Address - Country:US
Mailing Address - Phone:858-526-0890
Mailing Address - Fax:858-526-0899
Practice Address - Street 1:10066 PACIFIC HEIGHTS BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4211
Practice Address - Country:US
Practice Address - Phone:858-526-0890
Practice Address - Fax:858-526-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT15191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty