Healthcare Provider Details

I. General information

NPI: 1508278466
Provider Name (Legal Business Name): ALLEN WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 HOWE ST
OAKLAND CA
94611-5312
US

IV. Provider business mailing address

3801 HOWE ST
OAKLAND CA
94611-5312
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1190
  • Fax:
Mailing address:
  • Phone: 510-752-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2020-0475
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54573
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR74419
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD209993
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA160385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: