Provider Demographics
NPI:1427058684
Name:MA, LEONARD WONG (OD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:WONG
Last Name:MA
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 1:411 PRIMROSE RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-4009
Mailing Address - Country:US
Mailing Address - Phone:650-344-3112
Mailing Address - Fax:650-344-7218
Practice Address - Street 1:411 PRIMROSE RD
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4009
Practice Address - Country:US
Practice Address - Phone:650-344-3112
Practice Address - Fax:650-344-7218
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA6501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA6501OtherSTATE LICENSE NUMBER
CASD0065010Medicaid
CASD0065010Medicare PIN
CAT10341Medicare UPIN