Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 11979T | CA |
NPI | 1013069418 |
---|---|
Provider Name | David T Wong |
First Address | Rosemead, CA 91770-2411 |
Second Address | Valencia, CA 91355-1861 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U92015 | (02) | CA |