Provider Demographics
NPI:1184875759
Name:WONG, JOHNSON KAR TSUN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:KAR TSUN
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 1:14568A MONO WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8858
Mailing Address - Country:US
Mailing Address - Phone:209-768-1217
Mailing Address - Fax:209-533-2061
Practice Address - Street 1:14568A MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8858
Practice Address - Country:US
Practice Address - Phone:209-768-1217
Practice Address - Fax:209-533-2061
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2008-10-01
Deactivation Date:2008-08-21
Deactivation Code:
Reactivation Date:2008-10-01
Provider Licenses
StateLicense IDTaxonomies
CAG79608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72-1325399OtherPROVIDER TAX ID#
ZZZ04982ZOtherGROUP ID#
CA00G796080Medicaid
ZZZ04982ZOtherGROUP ID#
00G796082Medicare PIN