Provider Demographics
NPI:1891760260
Name:WONG, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
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 1:1380 LUSITANA ST
Mailing Address - Street 2:SUITE 506
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813
Mailing Address - Country:US
Mailing Address - Phone:808-524-6922
Mailing Address - Fax:808-524-6923
Practice Address - Street 1:1380 LUSITANA ST
Practice Address - Street 2:SUITE 506
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813
Practice Address - Country:US
Practice Address - Phone:808-524-6922
Practice Address - Fax:808-524-6923
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2020-09-24
Deactivation Date:2006-02-21
Deactivation Code:
Reactivation Date:2007-09-25
Provider Licenses
StateLicense IDTaxonomies
HIMD11352207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH54877Medicare PIN
HIH54878Medicare PIN
HIH39386Medicare UPIN