Healthcare Provider Details

I. General information

NPI: 1821207804
Provider Name (Legal Business Name): SEONG YEON PARK WONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SEONG PARK WONG MD

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

3540 CAMINITO CARMEL LNDG
SAN DIEGO CA
92130-2503
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-5288
  • Fax:
Mailing address:
  • Phone: 858-842-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA112159
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA112159
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA112159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: