Provider Demographics
NPI:1164787628
Name:WONG, SELENA CONSTANCE (OD)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:CONSTANCE
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:CONSTANCE
Other - Last Name:CHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:14726 RAMONA AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5730
Mailing Address - Country:US
Mailing Address - Phone:626-305-9100
Mailing Address - Fax:626-305-0152
Practice Address - Street 1:855 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-1938
Practice Address - Country:US
Practice Address - Phone:626-358-1080
Practice Address - Fax:626-358-0548
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002662152W00000X
CA33549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102733683Medicaid
CA1164787628Medicaid
PAOEG002662OtherLICENSE