Provider Demographics
NPI:1093906836
Name:WONG, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:201 S ALVARADO ST STE 618
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2386
Mailing Address - Country:US
Mailing Address - Phone:213-483-7766
Mailing Address - Fax:213-483-0735
Practice Address - Street 1:201 S ALVARADO ST STE 618
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2386
Practice Address - Country:US
Practice Address - Phone:213-483-7766
Practice Address - Fax:213-483-0735
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G101100Medicaid
CA00G101100Medicaid