Provider Demographics
NPI:1780620088
Name:WING, VIVIAN (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:WING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 OAK GROVE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2536
Mailing Address - Country:US
Mailing Address - Phone:925-296-7156
Mailing Address - Fax:925-296-7174
Practice Address - Street 1:2125 OAK GROVE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2536
Practice Address - Country:US
Practice Address - Phone:925-296-7156
Practice Address - Fax:925-296-7174
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG443672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300104403OtherRAILROAD MEDICARE
CA00G443670Medicare ID - Type Unspecified
CA00G443671Medicare ID - Type Unspecified
CAA49623Medicare UPIN