Healthcare Provider Details

I. General information

NPI: 1962400531
Provider Name (Legal Business Name): CALVIN K WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 09/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 WEST C STREET SUITE 185
SAN DIEGO CA
92101
US

IV. Provider business mailing address

444 WEST C STREET SUITE 185
SAN DIEGO CA
92101
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-6262
  • Fax: 619-232-6012
Mailing address:
  • Phone: 619-232-6262
  • Fax: 619-232-6012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG79819
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG79819
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberG79819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: