Provider Demographics
NPI:1013998616
Name:KIN C WONG MD A PROFESSIONAL CORP
Entity type:Organization
Organization Name:KIN C WONG MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-247-6676
Mailing Address - Street 1:435 ARDEN AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4014
Mailing Address - Country:US
Mailing Address - Phone:818-247-6676
Mailing Address - Fax:818-247-6076
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:STE 310
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1130
Practice Address - Country:US
Practice Address - Phone:818-247-6676
Practice Address - Fax:818-247-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33946207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A339960Medicaid
CA00A339960Medicaid
A27309Medicare UPIN