Provider Demographics
NPI:1255862736
Name:WONG, DEIRDRE O'SULLIVAN (MD)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:O'SULLIVAN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEIRDRE
Other - Middle Name:
Other - Last Name:O'SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6496
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91003-6496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1607842084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry