Provider Demographics
NPI:1790124162
Name:WONG, MICHELLE MIN-GEE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MIN-GEE
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 1:1598 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4465
Mailing Address - Country:US
Mailing Address - Phone:510-895-2116
Mailing Address - Fax:510-895-2316
Practice Address - Street 1:1598 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4465
Practice Address - Country:US
Practice Address - Phone:510-895-2116
Practice Address - Fax:510-895-2316
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 15300 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist