Provider Demographics
NPI:1609141068
Name:LO-GOMEZ, WINGSHAN (DO)
Entity Type:Individual
Prefix:
First Name:WINGSHAN
Middle Name:
Last Name:LO-GOMEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BRISTOL ST
Mailing Address - Street 2:STE C101
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5943
Mailing Address - Country:US
Mailing Address - Phone:424-218-6015
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:STE C101
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5943
Practice Address - Country:US
Practice Address - Phone:424-218-6015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOtherSTUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING