Healthcare Provider Details

I. General information

NPI: 1922325695
Provider Name (Legal Business Name): LESLIE WONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BROADWAY FL 3
OAKLAND CA
94611-5730
US

IV. Provider business mailing address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-6405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-137084
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number148563
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: