MEDICARE: MARCUS WONG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	1326571654	IL
2	207P00000X	Emergency Medicine Physician	01083798A	IN
3	390200000X	Student in an Organized Health Care Education/Training Program
4	207P00000X	Emergency Medicine Physician	A169829	CA

General Provider Information

NPI Number	:	1326571654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS WONG MD

Provider Business Mailing Address
First Line	:	10001 VENICE BLVD APT 315
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6499
Country	:	US
Telephone Number	:	619-300-6912
Fax Number	:

Provider Business Practice Location Address
First Line	:	10001 VENICE BLVD APT 315
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6499
Country	:	US
Telephone Number	:	619-300-6912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2017
Last Update Date	:	10/26/2024

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