Provider Demographics
NPI:1780638650
Name:WONG, JAMES G (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 RANCHO CONEJO BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-1448
Mailing Address - Country:US
Mailing Address - Phone:949-597-1377
Mailing Address - Fax:
Practice Address - Street 1:24451 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:949-452-3573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA818272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A818270OtherBLUE SHIELD
CAI62692Medicare UPIN
CAWA81827GMedicare PIN
CA00A818270OtherBLUE SHIELD
CAWA81827HMedicare PIN