Provider Demographics
NPI:1942320460
Name:WONG, KING (MD)
Entity Type:Individual
Prefix:
First Name:KING
Middle Name:
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 1:1818 N ORANGE GROVE AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3028
Mailing Address - Country:US
Mailing Address - Phone:909-620-7230
Mailing Address - Fax:
Practice Address - Street 1:1818 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3028
Practice Address - Country:US
Practice Address - Phone:909-620-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A354710174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A354710Medicaid
CA00A354710Medicaid