Provider Demographics
NPI:1770033565
Name:VISION GALLERY OPTOMETRIC CTR
Entity Type:Organization
Organization Name:VISION GALLERY OPTOMETRIC CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-881-4401
Mailing Address - Street 1:20211 PATIO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4338
Mailing Address - Country:US
Mailing Address - Phone:510-881-4401
Mailing Address - Fax:510-881-4423
Practice Address - Street 1:20211 PATIO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4338
Practice Address - Country:US
Practice Address - Phone:510-881-4401
Practice Address - Fax:510-881-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12872TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA121305Medicare PIN