Provider Demographics
NPI:1386619906
Name:WONG, WILDON C (OD)
Entity type:Individual
Prefix:MR
First Name:WILDON
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:7825 FAY AVENUE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-454-4699
Mailing Address - Fax:858-545-3797
Practice Address - Street 1:7825 FAY AVENUE
Practice Address - Street 2:SUITE 140
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-454-4699
Practice Address - Fax:858-545-3797
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11493T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U93909Medicare UPIN