Provider Demographics
NPI:1629265095
Name:WONG, CAROLYN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX629
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-0629
Mailing Address - Country:US
Mailing Address - Phone:323-264-6157
Mailing Address - Fax:
Practice Address - Street 1:3616 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2326
Practice Address - Country:US
Practice Address - Phone:323-264-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL1632213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAX878ZMedicare PIN