Provider Demographics
NPI:1558881292
Name:WONG, THEODORA (MD, RD)
Entity type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:
Last Name:WONG
Suffix:
Gender:
Credentials:MD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 E GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5220
Mailing Address - Country:US
Mailing Address - Phone:626-215-7996
Mailing Address - Fax:
Practice Address - Street 1:12801 CROSSROADS PKWY S
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3502
Practice Address - Country:US
Practice Address - Phone:562-463-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041101133V00000X
CAA187282208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered