Provider Demographics
NPI:1053504902
Name:WONG, GRACE I (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:I
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 W RIVERSIDE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4339
Mailing Address - Country:US
Mailing Address - Phone:818-563-1449
Mailing Address - Fax:818-563-1049
Practice Address - Street 1:3808 W RIVERSIDE DR STE 201
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4339
Practice Address - Country:US
Practice Address - Phone:818-563-1449
Practice Address - Fax:818-563-1049
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 432620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101996474Medicaid
CA1659648384OtherNPI TYP 2
PA101996474Medicaid