Healthcare Provider Details

I. General information

NPI: 1255534418
Provider Name (Legal Business Name): BRIAN WILLIAM WONG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2492 WALNUT AVE STE 140
TUSTIN CA
92780-6953
US

IV. Provider business mailing address

2492 WALNUT AVE STE 140
TUSTIN CA
92780-6953
US

V. Phone/Fax

Practice location:
  • Phone: 714-544-2188
  • Fax:
Mailing address:
  • Phone: 714-544-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT13998
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT13998
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT13998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: