Provider Demographics
NPI:1487686473
Name:WONG, CLYDE YUEN (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:YUEN
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 1:77 W MARCH LN STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5724
Mailing Address - Country:US
Mailing Address - Phone:209-477-5552
Mailing Address - Fax:209-477-5553
Practice Address - Street 1:77 W MARCH LN STE A
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5724
Practice Address - Country:US
Practice Address - Phone:209-477-5552
Practice Address - Fax:209-477-5553
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G531660Medicaid
P00379497OtherMEDICARE RR
A52460Medicare UPIN