Provider Demographics
NPI:1851319834
Name:WONG, ANDREW C (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREW
Middle Name:C
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 1:259 MERIDIAN AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2905
Mailing Address - Country:US
Mailing Address - Phone:408-297-9852
Mailing Address - Fax:408-297-9859
Practice Address - Street 1:259 MERIDIAN AVE STE 15
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2905
Practice Address - Country:US
Practice Address - Phone:408-297-9852
Practice Address - Fax:408-297-9859
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52688208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A526881Medicaid
CA00A526881Medicare ID - Type Unspecified
CA00A526881Medicaid