Healthcare Provider Details

I. General information

NPI: 1437334232
Provider Name (Legal Business Name): MICHELINE JOELLE WONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST BOX 3
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

5601 DE SOTO AVE
WOODLAND HILLS CA
91367-6701
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-3563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA89341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: