Provider Demographics
NPI:1043394364
Name:WONG, MICHAEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:WONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15520 ROCKFIELD BLVD A200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-6705
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:401 GRAND AVENUE
Practice Address - Street 2:370
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-5046
Practice Address - Country:US
Practice Address - Phone:510-444-1116
Practice Address - Fax:510-444-1180
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC15075OtherCHIROPRACTIC LICENSE
CADC0150750OtherBLUE SHIELD
CADC0150750Medicare PIN
CAT05624Medicare UPIN