Provider Demographics
NPI:1336201615
Name:WONG, KEITH YUN KONG (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:YUN KONG
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 1:1608 LAVENDER LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3771
Mailing Address - Country:US
Mailing Address - Phone:209-521-5709
Mailing Address - Fax:
Practice Address - Street 1:3401 DALE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0505
Practice Address - Country:US
Practice Address - Phone:209-574-0710
Practice Address - Fax:209-529-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8152T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081520Medicaid
CACA8152OtherEYEMED
CA14062OtherMES
CA8152TOtherSTATE LICENSE
CA8152TOtherSTATE LICENSE
SD0081522Medicare PIN
CACA8152OtherEYEMED