Provider Demographics
NPI:1245771112
Name:WONG, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11590 PETENWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3648
Mailing Address - Country:US
Mailing Address - Phone:919-619-8820
Mailing Address - Fax:
Practice Address - Street 1:7330 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1124
Practice Address - Country:US
Practice Address - Phone:858-292-4498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33633TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist