Provider Demographics
NPI:1497816136
Name:WONG, CECIL C (OD)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:C
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 1:490 S LENOLA RD STE B
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-1618
Mailing Address - Country:US
Mailing Address - Phone:856-787-9875
Mailing Address - Fax:856-787-9754
Practice Address - Street 1:490 S LENOLA RD STE B
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-1618
Practice Address - Country:US
Practice Address - Phone:856-787-9875
Practice Address - Fax:856-787-9754
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00484700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJAM500410Medicare ID - Type Unspecified
NJU38119Medicare UPIN