Healthcare Provider Details

I. General information

NPI: 1821348392
Provider Name (Legal Business Name): CHARLES D WONG DO MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 STOCKDALE HWY SUITE 109
BAKERSFIELD CA
93311-3620
US

IV. Provider business mailing address

PO BOX 2287
BAKERSFIELD CA
93303-2287
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-6550
  • Fax: 661-663-6259
Mailing address:
  • Phone: 661-324-0300
  • Fax: 661-324-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A8787
License Number StateCA

VIII. Authorized Official

Name: CHARLES D WONG
Title or Position: PRESIDENT
Credential: DO
Phone: 661-324-0300