Provider Demographics
NPI:1134211725
Name:WONG, TOM KIEN (OD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:KIEN
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 1:731 SOUTH DEL MAR AVE
Mailing Address - Street 2:#F
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776
Mailing Address - Country:US
Mailing Address - Phone:626-319-6100
Mailing Address - Fax:
Practice Address - Street 1:477 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2024
Practice Address - Country:US
Practice Address - Phone:626-796-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11324T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113240Medicaid
U80444Medicare UPIN
CASD0113240Medicaid