Provider Demographics
NPI:1225021017
Name:WONG, ALEXANDER (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:WONG
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 1:288 N LA CADENA DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2926
Mailing Address - Country:US
Mailing Address - Phone:909-825-2020
Mailing Address - Fax:909-825-0152
Practice Address - Street 1:555 E PACIFIC COAST HWY
Practice Address - Street 2:STE 101
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5579
Practice Address - Country:US
Practice Address - Phone:562-494-9958
Practice Address - Fax:562-494-0950
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASD0104450152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104450Medicaid
CA5876520001Medicare NSC
CAAQ103AMedicare PIN
CA1366716912Medicare PIN
CASD0104450Medicare PIN
CASD0104450Medicaid