Provider Demographics
NPI:1770569386
Name:WANG, MINGJUN MICHAEL (O D)
Entity type:Individual
Prefix:DR
First Name:MINGJUN
Middle Name:MICHAEL
Last Name:WANG
Suffix:
Gender:M
Credentials:O D
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:O D
Mailing Address - Street 1:10066 PACIFIC HEIGHTS BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4211
Mailing Address - Country:US
Mailing Address - Phone:858-526-0890
Mailing Address - Fax:858-526-0899
Practice Address - Street 1:10066 PACIFIC HEIGHTS BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4211
Practice Address - Country:US
Practice Address - Phone:858-526-0890
Practice Address - Fax:858-526-0899
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPA09830OtherVBA
PA2159259830OtherVSP
PA2179183000OtherKEYSTONE HEALTH PLAN EAST
PA42203OtherDAVIS VISION
PR20031OtherSPECTERA
PA397523OtherNVA
PAWA1489384OtherHIGH MARK BLUE SHIELD
PA001973771Medicaid
PA348399OtherAETNA
PA1489384OtherPERSONAL CHOICE
PA348399OtherAETNA
PA1770569386Medicare PIN