Provider Demographics
NPI:1255587549
Name:WONG, DUSTIN (DO)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16455 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16455 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3554
Practice Address - Country:US
Practice Address - Phone:760-947-2161
Practice Address - Fax:760-947-3673
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine