Provider Demographics
NPI:1093702151
Name:WONG, EDWARD KERN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:KERN
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 1:14911 NATIONAL AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2632
Mailing Address - Country:US
Mailing Address - Phone:408-356-9121
Mailing Address - Fax:408-356-4628
Practice Address - Street 1:14911 NATIONAL AVE
Practice Address - Street 2:STE 3
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2632
Practice Address - Country:US
Practice Address - Phone:408-356-9121
Practice Address - Fax:408-356-4628
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0082830Medicaid
E96989Medicare UPIN
CAGR0082830Medicaid