Healthcare Provider Details

I. General information

NPI: 1528555869
Provider Name (Legal Business Name): THOMAS WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 UTAH AVE STE 200
EL SEGUNDO CA
90245-4817
US

IV. Provider business mailing address

1801 S OSPREY AVE UNIT 101
SARASOTA FL
34239-3608
US

V. Phone/Fax

Practice location:
  • Phone: 281-766-0959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number63753
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME19350
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: