Provider Demographics
NPI:1215191846
Name:WONG, DENISE RAE (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:RAE
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 1:595 BUCKINGHAM WAY
Mailing Address - Street 2:SUITE 324
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 BUCKINGHAM WAY
Practice Address - Street 2:SUITE 324
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1911
Practice Address - Country:US
Practice Address - Phone:415-665-1877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117618207YS0123X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program