Provider Demographics
NPI:1891895850
Name:WONG, LENBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:LENBERT
Middle Name:M
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3100 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3866
Practice Address - Country:US
Practice Address - Phone:916-774-8500
Practice Address - Fax:916-782-2857
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG63296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G632960Medicaid
CA00G632960Medicaid
00G632961Medicare ID - Type Unspecified