Provider Demographics
NPI:1700543196
Name:WONG, MELISSA SUSAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUSAN
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9009 GREAT HILLS TRL APT 2724
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10601 PECAN PARK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1325
Practice Address - Country:US
Practice Address - Phone:512-401-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10383T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy