Provider Demographics
NPI:1033113600
Name:WONG, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 GENESEE AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4964
Mailing Address - Country:US
Mailing Address - Phone:858-268-0300
Mailing Address - Fax:858-268-3894
Practice Address - Street 1:4282 GENESEE AVE
Practice Address - Street 2:STE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4964
Practice Address - Country:US
Practice Address - Phone:858-268-0300
Practice Address - Fax:858-268-3894
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34771207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G347710Medicaid
CA00G347710OtherBLUESHIELD PROV ID
CAA46071Medicare UPIN
CAG34771Medicare ID - Type Unspecified