Healthcare Provider Details

I. General information

NPI: 1386977288
Provider Name (Legal Business Name): GREGORY KELII WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-4099
  • Fax: 714-509-3301
Mailing address:
  • Phone: 714-509-4099
  • Fax: 714-509-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberN7765
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA124939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: