Provider Demographics
NPI:1265446686
Name:WONG, DARRELL W (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:W
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 1:705 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5657
Mailing Address - Country:US
Mailing Address - Phone:480-897-6992
Mailing Address - Fax:480-839-1874
Practice Address - Street 1:705 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5657
Practice Address - Country:US
Practice Address - Phone:480-897-6992
Practice Address - Fax:480-839-1874
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28509207K00000X
CAA61833207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H30828Medicare UPIN
85190Medicare ID - Type Unspecified