Active NPI
Clinton King Wong, O.D.
- Optometrist
- Moreno Valley, CA
National Provider Identifier
1619003944
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 7725T
- Practice address
- 12810 Heacock St
Suite B104
Moreno Valley, CA 92553-2854 - Phone
- (951) 924-2020
- Fax
- (951) 924-7136
- NPI assigned
- Feb 23, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 7725T | CA | Primary |
Addresses
Primary practice location
12810 Heacock St
Suite B104
Moreno Valley, CA 92553-2854
Mailing address
12810 Heacock St
Suite B104
Moreno Valley, CA 92553-2854
Phone (951) 924-2020
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| SD0077250 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100928000575 | CA | Practitioner - Optometry | 7517083538 | Practice locations: Moreno Valley, CA |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7725 | CA | MD | Addiction (Substance Use Disorder) Counselor |
| 7725T | CA | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172188800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1619003944",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12810 HEACOCK ST",
"address_2": "SUITE B104",
"city": "MORENO VALLEY",
"state": "CA",
"postal_code": "925532854",
"telephone_number": "951-924-2020",
"fax_number": "951-924-7136"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12810 HEACOCK ST",
"address_2": "SUITE B104",
"city": "MORENO VALLEY",
"state": "CA",
"postal_code": "925532854",
"telephone_number": "951-924-2020",
"fax_number": "951-924-7136"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WONG",
"first_name": "CLINTON",
"middle_name": "KING",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-02-23",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "CA",
"license": "7725T",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "SD0077250",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Moreno Valley, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.