Basic Information
| Provider Information | |||||||||
| NPI: | 1700543196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9009 GREAT HILLS TRL APT 2724 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787597148 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10601 PECAN PARK BLVD STE 201 | ||||||||
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| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787501325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124010400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2021 | ||||||||
| LastUpdateDate: | 11/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WV0400X | 10383T | TX | Y | Eye and Vision Services Providers | Optometrist | Vision Therapy |
No ID Information.