Provider Demographics
NPI:1689092397
Name:JONG, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:JONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 SAWTELLE BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7014
Practice Address - Country:US
Practice Address - Phone:310-231-3001
Practice Address - Fax:310-231-3095
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35991208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation