Provider Demographics
NPI:1508109182
Name:WONG, JOHN WC (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WC
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 1:1613 CHELSEA RD # 803
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2419
Mailing Address - Country:US
Mailing Address - Phone:626-795-8082
Mailing Address - Fax:626-795-8087
Practice Address - Street 1:1613 CHELSEA RD # 803
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2419
Practice Address - Country:US
Practice Address - Phone:626-795-8082
Practice Address - Fax:626-795-8087
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACFE27640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist