Provider Demographics
NPI:1700931698
Name:WONG, WENDELL P (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:P
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:23550 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE #220, BUILDING 1
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4731
Mailing Address - Country:US
Mailing Address - Phone:310-784-2020
Mailing Address - Fax:310-784-2021
Practice Address - Street 1:23550 HAWTHORNE BLVD
Practice Address - Street 2:SUITE #220, BUILDING 1
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4731
Practice Address - Country:US
Practice Address - Phone:310-784-2020
Practice Address - Fax:310-784-2021
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG38296152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47431Medicare UPIN