Provider Demographics
NPI:1871542449
Name:MAMIE WONG O.D. PLLC
Entity type:Organization
Organization Name:MAMIE WONG O.D. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-524-5768
Mailing Address - Street 1:10000 AURORA AVE N
Mailing Address - Street 2:SUITE #6
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9346
Mailing Address - Country:US
Mailing Address - Phone:206-524-5768
Mailing Address - Fax:
Practice Address - Street 1:10000 AURORA AVE N
Practice Address - Street 2:SUITE #6
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9346
Practice Address - Country:US
Practice Address - Phone:206-524-5768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9317WOOtherREGENCE BLUE SHIELD
WAWA0704WOOtherNORTHWEST BENEFIT ADMINIS
WA2016335Medicaid