Provider Demographics
NPI:1386654200
Name:WONG, DAVID T (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
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 1:5801 NORRIS CANYON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5440
Mailing Address - Country:US
Mailing Address - Phone:925-275-9966
Mailing Address - Fax:
Practice Address - Street 1:5801 NORRIS CANYON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5440
Practice Address - Country:US
Practice Address - Phone:925-275-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG071461207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57371ZOtherBC/BS
CAZZZ17955ZMedicare ID - Type UnspecifiedMEDICARE