Provider Demographics
NPI:1114231222
Name:KONG-TAY WU, M.D, INC
Entity Type:Organization
Organization Name:KONG-TAY WU, M.D, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KONG-TAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-622-6433
Mailing Address - Street 1:1818 N ORANGE GROVE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3028
Mailing Address - Country:US
Mailing Address - Phone:909-988-8203
Mailing Address - Fax:909-988-5006
Practice Address - Street 1:437 N CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4229
Practice Address - Country:US
Practice Address - Phone:909-622-6433
Practice Address - Fax:909-469-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083540Medicaid