Healthcare Provider Details

I. General information

NPI: 1518549328
Provider Name (Legal Business Name): DUSTIN WONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17234 VALLEY BLVD BUILDING A
FONTANA CA
92335
US

IV. Provider business mailing address

17234 VALLEY BLVD BUILDING A
FONTANA CA
92335
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-5679
  • Fax:
Mailing address:
  • Phone: 909-427-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOT020545
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20A22709
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A22709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: