Provider Demographics
NPI:1508805011
Name:WONG, VIVIAN W (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:W
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 FIRWOOD ROW
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-0922
Mailing Address - Country:US
Mailing Address - Phone:858-729-0165
Mailing Address - Fax:858-729-0165
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:(VISTA COMMUNITY CLINIC)
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWO A33383Medicare ID - Type Unspecified
CAH52287Medicare UPIN