Provider Demographics
NPI:1467423301
Name:WONG, GRACE K (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:K
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6043 AGNES AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1708
Mailing Address - Country:US
Mailing Address - Phone:626-451-6803
Mailing Address - Fax:
Practice Address - Street 1:80 N LAKE AVE
Practice Address - Street 2:#102
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5626
Practice Address - Country:US
Practice Address - Phone:626-356-8088
Practice Address - Fax:626-356-8078
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10607T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106070Medicaid
CAU77652Medicare UPIN
CACX220ZMedicare PIN