Provider Demographics
NPI:1417051657
Name:WONG, VINCENT W (DPM)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:W
Last Name:WONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 PACIFIC AVE
Mailing Address - Street 2:SUITE 606
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-4457
Mailing Address - Country:US
Mailing Address - Phone:415-398-5023
Mailing Address - Fax:415-398-5580
Practice Address - Street 1:728 PACIFIC AVE
Practice Address - Street 2:SUITE 606
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4457
Practice Address - Country:US
Practice Address - Phone:415-398-5023
Practice Address - Fax:415-398-5580
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3798213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3798OtherMEDICAL LICENSE
CAU35694Medicare UPIN
CA000E37980Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAE3798OtherMEDICAL LICENSE