Provider Demographics
NPI:1265473789
Name:WONG, JONATHAN T (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:T
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 1:12420 FM 1960 RD W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4809
Mailing Address - Country:US
Mailing Address - Phone:832-237-1688
Mailing Address - Fax:832-237-3905
Practice Address - Street 1:12420 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4809
Practice Address - Country:US
Practice Address - Phone:832-237-1688
Practice Address - Fax:832-237-3905
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5607TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1996Medicare ID - Type UnspecifiedINDIVIDUAL