Provider Demographics
NPI:1639308885
Name:WONG, CARSON KATSUN (OD)
Entity Type:Individual
Prefix:DR
First Name:CARSON
Middle Name:KATSUN
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 1:44 SYLVAN AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 SYLVAN AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2417
Practice Address - Country:US
Practice Address - Phone:201-592-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007444-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0314081Medicaid
NY03160372Medicaid
NJ257427YKL8Medicare PIN
NY03160372Medicaid