Provider Demographics
NPI:1104200922
Name:WONG, KEITH (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W HEDDING ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 LOMITA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2076
Practice Address - Country:US
Practice Address - Phone:310-534-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA145273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine