Provider Demographics
NPI:1023170073
Name:WONG, IVAN (OD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
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 1:7 BACKUS AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7493
Mailing Address - Country:US
Mailing Address - Phone:203-743-9897
Mailing Address - Fax:203-743-6419
Practice Address - Street 1:7 BACKUS AVE STE 250
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7493
Practice Address - Country:US
Practice Address - Phone:203-743-9897
Practice Address - Fax:203-743-6419
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002529152W00000X, 152WC0802X, 152WX0102X
CTCT2529152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT09002529CT01OtherANTHEM BLUE CROSS BLUE SH
CT7058856OtherAETNA
CT7058856OtherAETNA