Provider Demographics
NPI:1972685949
Name:WONG, WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:WADE
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 1:9300 CAMPUS POINT DR
Mailing Address - Street 2:MAIL CODE 7756
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-657-6650
Mailing Address - Fax:
Practice Address - Street 1:9300 CAMPUS POINT DR
Practice Address - Street 2:7756
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-657-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A3872207LP2900X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX38720Medicaid
CAW20A3872BMedicare PIN
CAW20A3872AMedicare PIN
CA00AX38720Medicaid