1457345563 NPI number — DR. RANDY LAI YUU WONG O.D.

Table of content: DR. RANDY LAI YUU WONG O.D. (NPI 1457345563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457345563 NPI number — DR. RANDY LAI YUU WONG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
RANDY
Provider Middle Name:
LAI YUU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457345563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/24/2006
NPI Reactivation Date:
04/06/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22511 HIGHWAY 99 112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98026-8398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-670-9888
Provider Business Mailing Address Fax Number:
425-670-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22511 HIGHWAY 99
Provider Second Line Business Practice Location Address:
STE 112
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-8398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-670-9888
Provider Business Practice Location Address Fax Number:
425-670-2402
Provider Enumeration Date:
09/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD00003999 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2033587 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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