Provider Demographics
NPI:1063499325
Name:WONG, RICHARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:WONG
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Gender:M
Credentials:MD
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Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:SUITE 707
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2804
Mailing Address - Country:US
Mailing Address - Phone:818-345-5580
Mailing Address - Fax:818-774-0458
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:SUITE 707
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2804
Practice Address - Country:US
Practice Address - Phone:818-345-5580
Practice Address - Fax:818-774-0458
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-11-30
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Provider Licenses
StateLicense IDTaxonomies
CAA64059207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13138Medicare PIN