Provider Demographics
NPI:1245457118
Name:MICHAEL WONG OD LLC
Entity type:Organization
Organization Name:MICHAEL WONG OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KH
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-735-7633
Mailing Address - Street 1:1401 S BERETANIA ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1870
Mailing Address - Country:US
Mailing Address - Phone:808-735-7633
Mailing Address - Fax:808-735-2400
Practice Address - Street 1:1401 S BERETANIA ST
Practice Address - Street 2:SUITE 340
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1870
Practice Address - Country:US
Practice Address - Phone:808-735-7633
Practice Address - Fax:808-735-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05158901Medicaid
HI05158901Medicaid
HI0363290001Medicare NSC
HI0000PCBMTMedicare ID - Type UnspecifiedDR. MICHAEL K.H. WONG O.D