Provider Demographics
NPI:1871678557
Name:KING YUE WONG OD INC
Entity type:Organization
Organization Name:KING YUE WONG OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KING
Authorized Official - Middle Name:YUE
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-471-9618
Mailing Address - Street 1:316 SOUTH KENTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4022
Mailing Address - Country:US
Mailing Address - Phone:310-471-9618
Mailing Address - Fax:310-450-8580
Practice Address - Street 1:1431 SEVENTH STREET
Practice Address - Street 2:SUITE #201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2638
Practice Address - Country:US
Practice Address - Phone:310-450-9998
Practice Address - Fax:310-450-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12461TPA152W00000X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124611OtherMEDI CAL
CASD0124610Medicaid
CASD0124611OtherMEDI CAL
CASD0124610Medicaid