Provider Demographics
NPI:1992741763
Name:WONG, JOSEPH DAVID (OD , CRA)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:DAVID
Last Name:WONG
Suffix:
Gender:M
Credentials:OD , CRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 CHARING CROSS RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 ROSSMOOR PKWY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2501
Practice Address - Country:US
Practice Address - Phone:925-988-7560
Practice Address - Fax:925-256-6392
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5795T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0057950Medicare ID - Type Unspecified
CAT10123Medicare UPIN