Provider Demographics
NPI:1134208358
Name:TOM, WESLEY FONG (OD)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:FONG
Last Name:TOM
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 1:942 N BROADWAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1707
Mailing Address - Country:US
Mailing Address - Phone:213-680-9393
Mailing Address - Fax:213-680-2921
Practice Address - Street 1:942 N BROADWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1707
Practice Address - Country:US
Practice Address - Phone:213-680-9393
Practice Address - Fax:213-680-2921
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9469T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0946900Medicaid
WY076OtherMEDICARE LEGACY
X15393OtherMEDICARE LEGACY
WOP9469AOtherMEDICARE LEGACY
CAX15393Medicare UPIN
CAWY076Medicare PIN
CAWOP9469AMedicare PIN