Provider Demographics
NPI:1184628695
Name:WONG, KENNETH KAN TIN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KAN TIN
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3050
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA704482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I07929Medicare UPIN
I07929Medicare UPIN