Provider Demographics
NPI:1275609463
Name:WONG, BEN HAROLD JR (OD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:HAROLD
Last Name:WONG
Suffix:JR
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 1:1940 BLACK LAKE BLVD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5651
Mailing Address - Country:US
Mailing Address - Phone:360-570-1780
Mailing Address - Fax:360-570-1801
Practice Address - Street 1:1940 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5651
Practice Address - Country:US
Practice Address - Phone:360-570-1780
Practice Address - Fax:360-570-1801
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015162Medicaid
WA4198630001Medicare NSC
WAU26719Medicare UPIN
WAAB28021Medicare PIN