Provider Demographics
NPI:1841392032
Name:WONG, LI CHIUNG (MD)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:CHIUNG
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5225
Mailing Address - Country:US
Mailing Address - Phone:626-254-0854
Mailing Address - Fax:
Practice Address - Street 1:420 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3001
Practice Address - Country:US
Practice Address - Phone:626-919-5724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A607360Medicaid
CA00A607360Medicaid