Provider Demographics
NPI:1649244674
Name:WONG, LYNDON CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNDON
Middle Name:CHARLES
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:5330B SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-4116
Practice Address - Country:US
Practice Address - Phone:704-525-9802
Practice Address - Fax:704-523-2862
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT 005474152W00000X
NC2252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244528Medicaid
NYU45710Medicare UPIN
NY00244528Medicaid