Healthcare Provider Details

I. General information

NPI: 1346009644
Provider Name (Legal Business Name): BRANDON JOHN WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 525
ORANGE CA
92868-4553
US

IV. Provider business mailing address

505 S MAIN ST STE 525
ORANGE CA
92868-4553
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8547
  • Fax:
Mailing address:
  • Phone: 714-509-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number204253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: