MEDICARE: MICHAEL C. WONG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G34771	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00G347710	OTHER	CA	BLUESHIELD PROV ID

General Provider Information

NPI Number	:	1033113600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL C. WONG MD

Provider Business Mailing Address
First Line	:	4282 GENESEE AVE
Second Line	:	STE 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-4964
Country	:	US
Telephone Number	:	858-268-0300
Fax Number	:	858-268-3894

Provider Business Practice Location Address
First Line	:	4282 GENESEE AVE
Second Line	:	STE 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-4964
Country	:	US
Telephone Number	:	858-268-0300
Fax Number	:	858-268-3894

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	01/14/2008

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