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: | |
Other - Last Name Type: | |
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
State | License ID | Taxonomies |
---|---|---|
CA | A95311 | 207L00000X, 207L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 265587000 | Medicaid | |
CA | CC063Z | Medicare PIN | |
CA | CC063Y | Medicare PIN | |
CA | CB212857 | Medicare PIN | |
FL | AG996Z/K8875 | Medicare PIN | |
CA | P01474956 | Medicare PIN | |
CA | P00776559 | Medicare PIN |