Provider Demographics
NPI:1508085150
Name:BOWEN Y. WONG MD
Entity Type:Organization
Organization Name:BOWEN Y. WONG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-663-6658
Mailing Address - Street 1:3100 TELEGRAPH AVE STE 1000
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3210
Mailing Address - Country:US
Mailing Address - Phone:510-663-6658
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE STE 1000
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3210
Practice Address - Country:US
Practice Address - Phone:510-663-6658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG058245261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114986742OtherNPI
CA1114986742OtherNPI