Provider Demographics
NPI:1174509723
Name:WONG, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23622 CALABASAS RD
Mailing Address - Street 2:STE 250
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1549
Mailing Address - Country:US
Mailing Address - Phone:818-591-3435
Mailing Address - Fax:
Practice Address - Street 1:23622 CALABASAS RD
Practice Address - Street 2:STE 250
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1549
Practice Address - Country:US
Practice Address - Phone:818-591-3435
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37201208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice