Provider Demographics
NPI:1306971429
Name:WONG, CAROLYN MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:MARIE
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7905
Mailing Address - Country:US
Mailing Address - Phone:310-473-5464
Mailing Address - Fax:310-473-2536
Practice Address - Street 1:11540 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7905
Practice Address - Country:US
Practice Address - Phone:310-473-5464
Practice Address - Fax:310-473-2536
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP7450152W00000X
CA7450T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074500Medicaid
CAOP7450Medicare PIN
CAU24090Medicare UPIN
CA0918300001Medicare NSC