Provider Demographics
NPI:1639345184
Name:WONG, GORDON K (MD, PHD, MPH)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:K
Last Name:WONG
Suffix:
Gender:M
Credentials:MD, PHD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3433
Mailing Address - Country:US
Mailing Address - Phone:626-382-1263
Mailing Address - Fax:626-382-1252
Practice Address - Street 1:409 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3433
Practice Address - Country:US
Practice Address - Phone:626-382-1263
Practice Address - Fax:626-382-1252
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA717512083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51622Medicare UPIN