Provider Demographics
NPI:1336471440
Name:WONG, KING YUE (OD)
Entity Type:Individual
Prefix:DR
First Name:KING
Middle Name:YUE
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 1:316 S KENTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4022
Mailing Address - Country:US
Mailing Address - Phone:310-471-9618
Mailing Address - Fax:310-450-8580
Practice Address - Street 1:1431 7TH ST
Practice Address - Street 2:SUITE # 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2637
Practice Address - Country:US
Practice Address - Phone:310-395-2106
Practice Address - Fax:310-450-8580
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12461TPA152W00000X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124611OtherMEDICAID (2ND OFFICE)
CA1871678557OtherNPI # (ORGANIZATION & GROUP)
CASD0124610Medicaid
CAV07637Medicare UPIN
CASD0124611OtherMEDICAID (2ND OFFICE)