MEDICARE: GRACE I WONG M.D.

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	207R00000X	Internal Medicine Physician	MD 432620	PA

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	1659648384	OTHER	CA	NPI TYP 2

General Provider Information

NPI Number	:	1053504902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE I WONG M.D.

Provider Business Mailing Address
First Line	:	3808 W RIVERSIDE DR STE 201
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4339
Country	:	US
Telephone Number	:	818-563-1449
Fax Number	:	818-563-1049

Provider Business Practice Location Address
First Line	:	3808 W RIVERSIDE DR STE 201
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4339
Country	:	US
Telephone Number	:	818-563-1449
Fax Number	:	818-563-1049

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

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	12/28/2023

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