Provider Demographics
NPI:1972681963
Name:WONG, LAWRENCE DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DANIEL
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 1:2910 JEFFERSON ST
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2356
Mailing Address - Country:US
Mailing Address - Phone:760-729-8600
Mailing Address - Fax:760-729-1499
Practice Address - Street 1:2910 JEFFERSON ST
Practice Address - Street 2:SUITE # 100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2356
Practice Address - Country:US
Practice Address - Phone:760-729-8600
Practice Address - Fax:760-729-1499
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 51460207Q00000X
TXJ 0375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BW 3741089OtherDEA
BW 3741089OtherDEA
F 39543Medicare UPIN