Provider Demographics
NPI:1831169176
Name:WONG, GINA G (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:G
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:5050 LAGUNA BLVD
Mailing Address - Street 2:SUITE 112, #411
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4151
Mailing Address - Country:US
Mailing Address - Phone:832-265-8467
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:112 / I
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-366-5463
Practice Address - Fax:916-364-0187
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA11236T152W00000X
TX5630T152W00000X
OR2689T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU73635Medicare UPIN