Provider Demographics
NPI:1255302097
Name:WONG, WILSON SHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:SHEN
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 1047
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1047
Mailing Address - Country:US
Mailing Address - Phone:626-898-8610
Mailing Address - Fax:626-445-0482
Practice Address - Street 1:300 W HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007
Practice Address - Country:US
Practice Address - Phone:626-898-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG399632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300058011OtherRAILROAD MEDICARE
300037247OtherRAILROAD MEDICARE
A48035Medicare UPIN
300037247OtherRAILROAD MEDICARE
WG39963HMedicare ID - Type Unspecified
WG39963DMedicare ID - Type Unspecified
WG39963CMedicare ID - Type Unspecified