Provider Demographics
NPI:1700988011
Name:WING, THOMAS W (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:WING
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 1:6320 MACK RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4646
Mailing Address - Country:US
Mailing Address - Phone:916-421-3986
Mailing Address - Fax:916-421-5470
Practice Address - Street 1:6320 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4646
Practice Address - Country:US
Practice Address - Phone:916-421-3986
Practice Address - Fax:916-421-5470
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5794T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0057940Medicaid
CAT10122Medicare UPIN
CASD0057940Medicare ID - Type Unspecified
CA0434390001Medicare NSC