Provider Demographics
NPI:1457345563
Name:WONG, RANDY LAI YUU (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LAI YUU
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 1:22511 HIGHWAY 99 112
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8398
Mailing Address - Country:US
Mailing Address - Phone:425-670-9888
Mailing Address - Fax:425-670-2402
Practice Address - Street 1:22511 HIGHWAY 99
Practice Address - Street 2:STE 112
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8398
Practice Address - Country:US
Practice Address - Phone:425-670-9888
Practice Address - Fax:425-670-2402
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2019-01-15
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
WAOD00003999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2033587Medicaid