Provider Demographics
NPI:1457371619
Name:WONG, JOHN Y (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:Y
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 1:2047 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1024
Mailing Address - Country:US
Mailing Address - Phone:415-378-3595
Mailing Address - Fax:
Practice Address - Street 1:20211 PATIO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4338
Practice Address - Country:US
Practice Address - Phone:510-881-4401
Practice Address - Fax:510-881-4423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12872T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGC167ZMedicare PIN
CACA121305Medicare PIN