Healthcare Provider Details

I. General information

NPI: 1275550030
Provider Name (Legal Business Name): WALNUT CREEK PEDIATRIC MEDICAL GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 SAN MIGUEL DRIVE
WALNUT CREEK CA
94596
US

IV. Provider business mailing address

1822 SAN MIGUEL DRIVE
WALNUT CREEK CA
94596
US

V. Phone/Fax

Practice location:
  • Phone: 925-945-3580
  • Fax: 925-934-0471
Mailing address:
  • Phone: 925-945-3580
  • Fax: 925-934-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MONTGOMERY LAWTON KONG
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 925-945-3580