Provider Demographics
NPI:1902044951
Name:WONG, DEBORAH JEAN LEE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:JEAN LEE
Last Name:WONG
Suffix:
Gender:F
Credentials:MD, PHD
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Mailing Address - Street 1:2825 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLZ
Practice Address - Street 2:SUITE 550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-4955
Practice Address - Fax:310-443-0477
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2014-01-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA101243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABX418ZMedicare PIN