Provider Demographics
NPI:1659441525
Name:WONG, CRYSTAL S (OD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:S
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 S WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2013
Mailing Address - Country:US
Mailing Address - Phone:312-808-1893
Mailing Address - Fax:312-808-1834
Practice Address - Street 1:2349 S WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2013
Practice Address - Country:US
Practice Address - Phone:312-808-1893
Practice Address - Fax:312-808-1834
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist