Provider Demographics
NPI:1457813867
Name:WONG, GARRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
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 1:1708 CRYSTAL PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-5318
Mailing Address - Country:US
Mailing Address - Phone:909-519-1961
Mailing Address - Fax:
Practice Address - Street 1:11406 LOMA LINDA DR STE 516
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3711
Practice Address - Country:US
Practice Address - Phone:909-558-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4474208VP0000X, 2081P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program