Healthcare Provider Details

I. General information

NPI: 1871765305
Provider Name (Legal Business Name): ANDY WAI MING WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER EMERGENCY DEPARTMENT
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST 6G UHC
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8202
  • Fax:
Mailing address:
  • Phone: 313-993-2530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA112021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: