Provider Demographics
NPI:1790725539
Name:WONG, JACK K (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:K
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 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:541-773-3863
Mailing Address - Fax:541-776-2892
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-773-3863
Practice Address - Fax:541-776-2892
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50860207Q00000X
ORMD23319208D00000X
AZ34719208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF87333Medicare UPIN