Provider Demographics
NPI:1619003944
Name:WONG, CLINTON KING (OD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:KING
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 1:12810 HEACOCK ST
Mailing Address - Street 2:SUITE B104
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-2854
Mailing Address - Country:US
Mailing Address - Phone:951-924-2020
Mailing Address - Fax:951-924-7136
Practice Address - Street 1:12810 HEACOCK ST
Practice Address - Street 2:SUITE B104
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2854
Practice Address - Country:US
Practice Address - Phone:951-924-2020
Practice Address - Fax:951-924-7136
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7725T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077250Medicaid
CASD0077250Medicare ID - Type Unspecified
CASD0077250Medicaid