Provider Demographics
NPI:1508202201
Name:WONG, MICHELLE (OD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
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 1:38707 STIVERS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5337
Mailing Address - Country:US
Mailing Address - Phone:510-794-0660
Mailing Address - Fax:510-793-5044
Practice Address - Street 1:38707 STIVERS ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5337
Practice Address - Country:US
Practice Address - Phone:510-794-0660
Practice Address - Fax:510-793-5044
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8903152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist