Provider Demographics
NPI:1639214513
Name:JOHN LAI AND KEVIN WONG , MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JOHN LAI AND KEVIN WONG , MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-991-4466
Mailing Address - Street 1:1500 SOUTHGATE AVE
Mailing Address - Street 2:STE. 207
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2259
Mailing Address - Country:US
Mailing Address - Phone:650-991-4466
Mailing Address - Fax:650-991-4467
Practice Address - Street 1:1500 SOUTHGATE AVE
Practice Address - Street 2:STE. 207
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2259
Practice Address - Country:US
Practice Address - Phone:650-991-4466
Practice Address - Fax:650-991-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03771ZMedicare ID - Type Unspecified
CAZZZ03750ZMedicare PIN