Provider Demographics
NPI:1447338447
Name:WONG, GORDON G (OD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:G
Last Name:WONG
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 1:7825 FAY AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4247
Mailing Address - Country:US
Mailing Address - Phone:858-454-4699
Mailing Address - Fax:858-454-3797
Practice Address - Street 1:7825 FAY AVE STE 140
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4247
Practice Address - Country:US
Practice Address - Phone:858-454-4699
Practice Address - Fax:858-454-3797
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9832T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMW0672027OtherDEA
CAMW0672027OtherDEA