Provider Demographics
NPI:1235198854
Name:WONG, KENNETH KANG WA (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KANG WA
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 1:2211 S TELEGRAPH RD UNIT 7061
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-4802
Mailing Address - Country:US
Mailing Address - Phone:586-745-0863
Mailing Address - Fax:
Practice Address - Street 1:27118 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2915
Practice Address - Country:US
Practice Address - Phone:586-745-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004359152W00000X
NYTUV0065351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91573Medicare UPIN
NYDD2095Medicare ID - Type Unspecified