Provider Demographics
NPI:1477523991
Name:WONG, KEVIN MINGYIU (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MINGYIU
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 1:1500 SOUTHGATE AVE
Mailing Address - Street 2:207
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2259
Mailing Address - Country:US
Mailing Address - Phone:650-991-4466
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTHGATE AVE
Practice Address - Street 2:#115
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2259
Practice Address - Country:US
Practice Address - Phone:650-991-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG66973Medicare UPIN