Healthcare Provider Details

I. General information

NPI: 1699126730
Provider Name (Legal Business Name): JOEY TIMOTHY WONG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 N. SANTIAGO BLVD
ORANGE CA
92867-1862
US

IV. Provider business mailing address

2592 N. SANTIAGO BLVD
ORANGE CA
92867-1862
US

V. Phone/Fax

Practice location:
  • Phone: 885-434-7763
  • Fax: 949-281-5550
Mailing address:
  • Phone: 885-434-7763
  • Fax: 949-281-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number16167
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A16167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: