Provider Demographics
NPI:1932284817
Name:WONG, WINSTON C (MD)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
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 1:9561 MONTANZA WAY
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4263
Mailing Address - Country:US
Mailing Address - Phone:714-527-8943
Mailing Address - Fax:714-527-9086
Practice Address - Street 1:7872 WALKER ST
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1796
Practice Address - Country:US
Practice Address - Phone:714-527-8777
Practice Address - Fax:714-527-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45020207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0061190Medicaid
CA00A450200Medicaid
CAGR0061200Medicaid
CA5297826Medicare UPIN
CAWA45020BMedicare ID - Type UnspecifiedPPIN CERRITOS OFFICE
CAWA45020DMedicare ID - Type UnspecifiedPPIN BUENA PARK OFFICE
CA6277826Medicare UPIN
CAGR0061190Medicaid