Healthcare Provider Details

I. General information

NPI: 1528486479
Provider Name (Legal Business Name): KIMBERLY ANGELA WONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST #1100
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

4150 V ST #1100
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2737
  • Fax:
Mailing address:
  • Phone: 916-734-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA139747
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA139747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: