Provider Demographics
NPI:1295385193
Name:WONG, SAMANTHA (OD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S 3RD ST APT 2039
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-2169
Mailing Address - Country:US
Mailing Address - Phone:908-770-6716
Mailing Address - Fax:
Practice Address - Street 1:485 ROUTE 1 SOUTH
Practice Address - Street 2:BUILDING A
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830
Practice Address - Country:US
Practice Address - Phone:732-750-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009027152W00000X
NJ27OA00692700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist