Provider Demographics
NPI:1285830430
Name:WONG-SEFIDAN, IDA C (MD)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:C
Last Name:WONG-SEFIDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IDA
Other - Middle Name:C
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4661 GESNER PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6743
Mailing Address - Country:US
Mailing Address - Phone:917-232-4021
Mailing Address - Fax:
Practice Address - Street 1:402 DICKINSON ST
Practice Address - Street 2:MPF 3-320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6902
Practice Address - Country:US
Practice Address - Phone:619-543-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine