Healthcare Provider Details

I. General information

NPI: 1699710160
Provider Name (Legal Business Name): JOANNA M. WONG, M.D. A MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MANHATTAN BEACH BLVD SUITE 103
MANHATTAN BEACH CA
90266-4965
US

IV. Provider business mailing address

855 MANHATTAN BEACH BLVD SUITE 103
MANHATTAN BEACH CA
90266-4965
US

V. Phone/Fax

Practice location:
  • Phone: 310-939-7850
  • Fax: 310-939-7851
Mailing address:
  • Phone: 310-939-7850
  • Fax: 310-939-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG46405
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierG46405
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerMEDICAL LICENSE

VIII. Authorized Official

Name: DR. JOANNA M WONG
Title or Position: PRESIDENT
Credential: MD
Phone: 310-939-7850