Provider Demographics
NPI:1790728749
Name:WONG, TAN LIN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:LIN
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 1:2100 FOOTHILL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2905
Mailing Address - Country:US
Mailing Address - Phone:909-596-1941
Mailing Address - Fax:909-596-1943
Practice Address - Street 1:2100 FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2905
Practice Address - Country:US
Practice Address - Phone:909-596-1941
Practice Address - Fax:909-596-1943
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083450Medicaid
W20443OtherMEDICARE GROUP ID
CA00A504961Medicaid
W20443OtherMEDICARE GROUP ID
CAW13845Medicare ID - Type Unspecified
CAGR0083450Medicaid