Provider Demographics
NPI:1952363178
Name:WONG, DEBORAH F (MD)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:F
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:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:
Practice Address - Street 1:13975 MONO WAY STE G
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-2824
Practice Address - Country:US
Practice Address - Phone:209-533-9600
Practice Address - Fax:209-533-9608
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64641207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABW1699618OtherDEA
CABW1699618OtherDEA
CABW1699618OtherDEA