Provider Demographics
NPI:1689902447
Name:WONG, GLADYS (MT)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 JUNIPERO SERRA BLVD STE 590
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-1990
Mailing Address - Country:US
Mailing Address - Phone:650-992-5782
Mailing Address - Fax:650-756-9005
Practice Address - Street 1:2171 JUNIPERO SERRA BLVD STE 590
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1990
Practice Address - Country:US
Practice Address - Phone:650-992-5782
Practice Address - Fax:650-756-9005
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0844174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist