Healthcare Provider Details

I. General information

NPI: 1104808161
Provider Name (Legal Business Name): ERIC J WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 11/14/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29472 AVENIDA DE LAS BANDERA
RANCHO SANTA MARGARITA CA
92688-2651
US

IV. Provider business mailing address

29472 AVENIDA DE LAS BANDERA
RANCHO SANTA MARGARITA CA
92688-2651
US

V. Phone/Fax

Practice location:
  • Phone: 949-459-9968
  • Fax: 949-766-2565
Mailing address:
  • Phone: 949-459-9968
  • Fax: 949-766-2565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG75361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: