Provider Demographics
NPI:1114968393
Name:WONG, JACQUELINE C (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1336 W VALLEY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2480
Mailing Address - Country:US
Mailing Address - Phone:626-281-2232
Mailing Address - Fax:626-281-7214
Practice Address - Street 1:1336 W VALLEY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-2480
Practice Address - Country:US
Practice Address - Phone:626-281-2232
Practice Address - Fax:626-281-7214
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI20956Medicare UPIN