Provider Demographics
NPI:1457773822
Name:DORIS H WONG OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:DORIS H WONG OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-721-7167
Mailing Address - Street 1:5580 SPRINGDALE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3707
Mailing Address - Country:US
Mailing Address - Phone:925-463-3100
Mailing Address - Fax:925-463-3101
Practice Address - Street 1:5580 SPRINGDALE AVE STE E
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3707
Practice Address - Country:US
Practice Address - Phone:925-463-3100
Practice Address - Fax:925-463-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-20
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13121T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA113118Medicaid
CACA113118Medicare PIN