Provider Demographics
NPI:1811072861
Name:WONG, GORDON ALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ALVIN
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 1:3941 J ST
Mailing Address - Street 2:SUITE 354
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3624
Mailing Address - Country:US
Mailing Address - Phone:916-733-6870
Mailing Address - Fax:916-454-0490
Practice Address - Street 1:3941 J ST
Practice Address - Street 2:SUITE 354
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3624
Practice Address - Country:US
Practice Address - Phone:916-733-6870
Practice Address - Fax:916-454-0490
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22879Medicare UPIN