Provider Demographics
NPI:1922417518
Name:WONG, THOMAS WAI-TIM (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAI-TIM
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 1:4482 VILLAGE DR APT M
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-3758
Mailing Address - Country:US
Mailing Address - Phone:909-469-8773
Mailing Address - Fax:909-469-5228
Practice Address - Street 1:3 COLUMBUS CIR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-8760
Practice Address - Country:US
Practice Address - Phone:212-247-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15205TLG152W00000X
NY008704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB242473OtherMEDICARE PTAN SO CAL