Provider Demographics
NPI:1457419046
Name:WONG, ADAM KEN YIP (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:KEN YIP
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:9920 TALBERT AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-378-7000
Practice Address - Fax:714-647-1245
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95311207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265587000Medicaid
CACC063ZMedicare PIN
CACC063YMedicare PIN
CACB212857Medicare PIN
FLAG996Z/K8875Medicare PIN
CAP01474956Medicare PIN
CAP00776559Medicare PIN