Provider Demographics
NPI:1124020623
Name:WONG, CHRISTOPHER MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:MICHAEL
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 1:315 W WISTARIA AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007
Mailing Address - Country:US
Mailing Address - Phone:626-447-0721
Mailing Address - Fax:626-447-0721
Practice Address - Street 1:8622 GARVEY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770
Practice Address - Country:US
Practice Address - Phone:626-280-6898
Practice Address - Fax:626-280-6899
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-12-11
Deactivation Date:2005-11-10
Deactivation Code:
Reactivation Date:2006-12-13
Provider Licenses
StateLicense IDTaxonomies
CAA63500207R00000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A635000Medicaid
CAWA63500AMedicare ID - Type Unspecified
G99649Medicare UPIN