Provider Demographics
NPI:1326719907
Name:WONG, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:2225 23RD ST UNIT 309
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-3268
Mailing Address - Country:US
Mailing Address - Phone:626-217-5747
Mailing Address - Fax:
Practice Address - Street 1:200 MINOR HALL
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-0001
Practice Address - Country:US
Practice Address - Phone:510-642-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty