Provider Demographics
NPI:1649477167
Name:WONG-LOPEZ, JAIME (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:WONG-LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:WONG-DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NAVAL HEALTH CLINIC HAWAII
Mailing Address - Street 2:480 CENTRAL AVENUE
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:808-474-4242
Mailing Address - Fax:
Practice Address - Street 1:MCBH KANEOHE BAY BRANCH HEALTH CLINIC
Practice Address - Street 2:6905 HARRIS AVENUE
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-496-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101246156207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice