Healthcare Provider Details

I. General information

NPI: 1104036599
Provider Name (Legal Business Name): I LANE WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IRWIN LANE WONG M.D.

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALTON PKWY STE. 201
IRVINE CA
92606-5024
US

IV. Provider business mailing address

2500 ALTON PKWY STE. 201
IRVINE CA
92606-5024
US

V. Phone/Fax

Practice location:
  • Phone: 949-387-3888
  • Fax: 949-387-3907
Mailing address:
  • Phone: 949-387-3888
  • Fax: 949-387-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG59317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: