Provider Demographics
NPI:1841307535
Name:WONG, DAVID T (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:T
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:909-580-3353
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ARMC - MOB SUITE 308
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G8066402086S0102X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
H23521Medicare UPIN
CAGR0079700Medicaid
CA00G806640Medicare PIN