Provider Demographics
NPI:1851585020
Name:WONG, SUSAN SUI-SANG (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SUI-SANG
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:PO BOX 14858
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-1858
Mailing Address - Country:US
Mailing Address - Phone:510-713-7202
Mailing Address - Fax:510-713-7202
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:101
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-713-1300
Practice Address - Fax:510-792-7454
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27032Medicare UPIN