Provider Demographics
NPI:1417112392
Name:WONG, LINA LY (DO)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:LY
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LINA
Other - Middle Name:LY
Other - Last Name:EA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3006 SAN GABRIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2536
Mailing Address - Country:US
Mailing Address - Phone:626-773-8900
Mailing Address - Fax:
Practice Address - Street 1:3006 SAN GABRIEL BLVD
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2536
Practice Address - Country:US
Practice Address - Phone:626-773-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA12219207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program