Healthcare Provider Details

I. General information

NPI: 1699865741
Provider Name (Legal Business Name): KELLY KWOK WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 PACIFIC AVE # 703
SAN FRANCISCO CA
94133-4457
US

IV. Provider business mailing address

728 PACIFIC AVE # 703
SAN FRANCISCO CA
94133-4457
US

V. Phone/Fax

Practice location:
  • Phone: 415-805-7782
  • Fax: 415-805-7783
Mailing address:
  • Phone: 415-805-7782
  • Fax: 415-805-7783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA65226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: