Provider Demographics
NPI:1598323602
Name:JUSTIN WONG OD AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:JUSTIN WONG OD AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:WYMAN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-928-3612
Mailing Address - Street 1:474 MONROE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3656
Mailing Address - Country:US
Mailing Address - Phone:714-928-3612
Mailing Address - Fax:
Practice Address - Street 1:250 E YALE LOOP STE G
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4697
Practice Address - Country:US
Practice Address - Phone:949-333-7504
Practice Address - Fax:949-333-7503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty