Provider Demographics
NPI:1114149002
Name:WONG, JASON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
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 1:370 ALTAIR WAY
Mailing Address - Street 2:PMB #263
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086
Mailing Address - Country:US
Mailing Address - Phone:650-839-1447
Mailing Address - Fax:
Practice Address - Street 1:114 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063
Practice Address - Country:US
Practice Address - Phone:650-839-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG072282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine