Provider Demographics
NPI:1376744698
Name:WONG, LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
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 1:1294 W 6TH STREET
Mailing Address - Street 2:#205
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732
Mailing Address - Country:US
Mailing Address - Phone:310-514-8188
Mailing Address - Fax:310-514-0237
Practice Address - Street 1:1294 W 6TH STREET
Practice Address - Street 2:#205
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732
Practice Address - Country:US
Practice Address - Phone:310-514-8188
Practice Address - Fax:310-514-0237
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46233208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E02665Medicare UPIN
G46233Medicare ID - Type Unspecified