Provider Demographics
NPI:1912058603
Name:WONG, GAIL (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:WONG
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 1:3300 WEBSTER ST
Mailing Address - Street 2:#509
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3117
Mailing Address - Country:US
Mailing Address - Phone:510-452-2833
Mailing Address - Fax:510-452-2152
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:#509
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-452-2833
Practice Address - Fax:510-452-2152
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG032571207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45199Medicare UPIN
00G325710Medicare ID - Type Unspecified