Provider Demographics
NPI:1588635601
Name:WONG, PHILLIP JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOHN
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 1:818 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3106
Mailing Address - Country:US
Mailing Address - Phone:928-779-1297
Mailing Address - Fax:928-779-2198
Practice Address - Street 1:818 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3106
Practice Address - Country:US
Practice Address - Phone:928-779-1297
Practice Address - Fax:928-779-2198
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT76929Medicare UPIN
AZ527905830Medicare PIN
AZ0214920001Medicare NSC
AZ410021505Medicare PIN