Provider Demographics
NPI:1134199946
Name:WONG, DEREK ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALAN
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10833 LECONTE AVE
Mailing Address - Street 2:MDCC 12-334
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1732
Mailing Address - Country:US
Mailing Address - Phone:310-206-6581
Mailing Address - Fax:310-206-8616
Practice Address - Street 1:10833 LECONTE AVE
Practice Address - Street 2:MDCC 12-334
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1732
Practice Address - Country:US
Practice Address - Phone:310-206-6581
Practice Address - Fax:310-206-8616
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG73118207SG0201X, 207SG0202X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics