Healthcare Provider Details

I. General information

NPI: 1699778399
Provider Name (Legal Business Name): DOUGLAS S WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 N MILLBROOK AVE
FRESNO CA
93720-3347
US

IV. Provider business mailing address

1303 E HERNDON AVE SUITE 431
FRESNO CA
93720-3309
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-5500
  • Fax: 559-450-7473
Mailing address:
  • Phone: 559-450-3889
  • Fax: 559-450-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG45487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: