Healthcare Provider Details

I. General information

NPI: 1952342693
Provider Name (Legal Business Name): DARRYL S. WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3629 VISTA WAY
OCEANSIDE CA
92056-4522
US

IV. Provider business mailing address

3629 VISTA WAY
OCEANSIDE CA
92056-4522
US

V. Phone/Fax

Practice location:
  • Phone: 760-828-9200
  • Fax: 760-828-9141
Mailing address:
  • Phone: 760-828-9200
  • Fax: 760-828-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG70557
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG70557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: