Provider Demographics
NPI:1699987073
Name:WILLIAM Y S TOM & WESLEY F TOM PTRS
Entity type:Organization
Organization Name:WILLIAM Y S TOM & WESLEY F TOM PTRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:FONG
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:213-680-9393
Mailing Address - Street 1:942 N BROADWAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1707
Mailing Address - Country:US
Mailing Address - Phone:213-680-9393
Mailing Address - Fax:213-680-2921
Practice Address - Street 1:942 N BROADWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1707
Practice Address - Country:US
Practice Address - Phone:213-680-9393
Practice Address - Fax:213-680-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9469T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP9469AOtherMEDICARE LEGACY
CA0315920001Medicare NSC
CAWOP9469AMedicare PIN
CAWOP9469AOtherMEDICARE LEGACY
CAT69798Medicare UPIN
CAWY076Medicare ID - Type Unspecified