Provider Demographics
NPI:1417909722
Name:WONG, PRISCILLA DIK-CHIN (MD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:DIK-CHIN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:5555 W LAS POSITAS BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4000
Practice Address - Country:US
Practice Address - Phone:925-416-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG671482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G671480OtherBLUE SHIELD OF CA
CA00G671480Medicaid
CA00G671480Medicaid
CAWG67148CMedicare PIN
CAP00045033Medicare PIN
CAWG67148BMedicare PIN