Provider Demographics
NPI:1760403430
Name:MIKE V. WONG, O.D. A PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:MIKE V. WONG, O.D. A PROFESSIONAL CORP.
Other - Org Name:PASADENA EYECARE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:V
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-356-8088
Mailing Address - Street 1:80 N LAKE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-5626
Mailing Address - Country:US
Mailing Address - Phone:626-356-8088
Mailing Address - Fax:
Practice Address - Street 1:80 N LAKE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5626
Practice Address - Country:US
Practice Address - Phone:626-356-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10566T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5255160001Medicare NSC
CAWY204Medicare PIN