Provider Demographics
NPI:1972688513
Name:FONTANA OPTOMETRIC GROUP, INC.
Entity Type:Organization
Organization Name:FONTANA OPTOMETRIC GROUP, INC.
Other - Org Name:WILLIAM WONG AND DOUGLAS LEO, O.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-428-2020
Mailing Address - Street 1:8381 JUNIPER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3431
Mailing Address - Country:US
Mailing Address - Phone:909-428-2020
Mailing Address - Fax:844-274-0986
Practice Address - Street 1:16866 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3561
Practice Address - Country:US
Practice Address - Phone:909-350-1524
Practice Address - Fax:909-350-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06988152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48781YMedicaid
CAT10059Medicare UPIN
CAYYY48781YMedicaid
CAT10447Medicare UPIN