Healthcare Provider Details

I. General information

NPI: 1215034905
Provider Name (Legal Business Name): SAMUEL J WONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 TELEGRAPH AVE
BERKELEY CA
94705-2017
US

IV. Provider business mailing address

2905 TELEGRAPH AVE
BERKELEY CA
94705-2017
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-0411
  • Fax: 510-204-9086
Mailing address:
  • Phone: 510-841-4525
  • Fax: 510-845-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20A5983
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00AX59830
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
Identifier390004072
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: