Provider Demographics
NPI:1104036599
Name:WONG, I LANE (MD)
Entity Type:Individual
Prefix:
First Name:I
Middle Name:LANE
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IRWIN
Other - Middle Name:LANE
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2500 ALTON PKWY
Mailing Address - Street 2:STE. 201
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5024
Mailing Address - Country:US
Mailing Address - Phone:949-387-3888
Mailing Address - Fax:949-387-3907
Practice Address - Street 1:2500 ALTON PKWY
Practice Address - Street 2:STE. 201
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5024
Practice Address - Country:US
Practice Address - Phone:949-387-3888
Practice Address - Fax:949-387-3907
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59317OtherMEDICAL LICENSE NUMBER
CAINF1012OtherMONARCH HEALTHCARE ID
CA00G9317OtherBLUE SHIELD ID