Provider Demographics
NPI:1821054552
Name:WONG, RITCHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:RITCHIE
Middle Name:
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 1:3650 MISSION AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2933
Mailing Address - Country:US
Mailing Address - Phone:916-972-0882
Mailing Address - Fax:916-972-0649
Practice Address - Street 1:3650 MISSION AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2933
Practice Address - Country:US
Practice Address - Phone:916-972-0882
Practice Address - Fax:916-972-0649
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA758083183OtherRAILROAD MEDICARE
CA00G349230OtherBLUE SHIELD
CAG34923Medicaid
CAG34923Medicaid