Provider Demographics
NPI:1336294875
Name:WONG, GREGORY SAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SAN
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1700 CESAR CHAVEZ AVE #3900
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2414
Mailing Address - Country:US
Mailing Address - Phone:323-307-0800
Mailing Address - Fax:323-307-0803
Practice Address - Street 1:1700 CESAR CHAVEZ AVE
Practice Address - Street 2:SENIOR CARE CLINIC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2414
Practice Address - Country:US
Practice Address - Phone:323-307-0800
Practice Address - Fax:323-307-0803
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA96833207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A968330Medicaid
CAAW165ZMedicare UPIN