Provider Demographics
NPI:1699030940
Name:WONG, JUSTIN WYMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WYMAN
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 1:2280 E CARSON ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3044
Mailing Address - Country:US
Mailing Address - Phone:562-422-2020
Mailing Address - Fax:562-426-2214
Practice Address - Street 1:2280 E CARSON ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3044
Practice Address - Country:US
Practice Address - Phone:562-422-2020
Practice Address - Fax:562-426-2214
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist