Provider Demographics
NPI:1255335832
Name:WONG, GILBERT G (OD)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:G
Last Name:WONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5610 W TALAVI BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1878
Mailing Address - Country:US
Mailing Address - Phone:602-386-1153
Mailing Address - Fax:602-386-1156
Practice Address - Street 1:5610 W TALAVI BLVD
Practice Address - Street 2:STE 101
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1878
Practice Address - Country:US
Practice Address - Phone:602-386-1153
Practice Address - Fax:602-386-1156
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOD668152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT88255Medicare UPIN
AZ0183780001Medicare NSC
AZZOD668Medicare PIN