Healthcare Provider Details

I. General information

NPI: 1659648384
Provider Name (Legal Business Name): GRACE WONG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 W RIVERSIDE DR STE 201
BURBANK CA
91505-4339
US

IV. Provider business mailing address

3808 W RIVERSIDE DR STE 201
BURBANK CA
91505-4339
US

V. Phone/Fax

Practice location:
  • Phone: 818-563-1449
  • Fax:
Mailing address:
  • Phone: 626-347-9074
  • Fax: 818-509-5939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA96700
License Number StateCA

VIII. Authorized Official

Name: DR. GRACE WONG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-347-9074