Healthcare Provider Details

I. General information

NPI: 1912101452
Provider Name (Legal Business Name): RYAN WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S MAIN ST SUITE 100
ORANGE CA
92868-3851
US

IV. Provider business mailing address

230 S MAIN ST SUITE 100
ORANGE CA
92868-3851
US

V. Phone/Fax

Practice location:
  • Phone: 714-541-0101
  • Fax: 714-541-0450
Mailing address:
  • Phone: 714-541-0101
  • Fax: 714-541-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA106001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: