Provider Demographics
NPI:1225164619
Name:WONG, HARLAN JACK (OD)
Entity Type:Individual
Prefix:
First Name:HARLAN
Middle Name:JACK
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 1:1928 SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1022
Mailing Address - Country:US
Mailing Address - Phone:510-843-4030
Mailing Address - Fax:510-843-0151
Practice Address - Street 1:1928 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1022
Practice Address - Country:US
Practice Address - Phone:510-843-4030
Practice Address - Fax:510-843-0151
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9125T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist