MEDICARE: KENNETH KAN TIN 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	2085R0001X	Radiation Oncology Physician	A70448	CA

General Provider Information

NPI Number	:	1184628695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH KAN TIN WONG MD

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-865-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 EASTLAKE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0112
Country	:	US
Telephone Number	:	323-865-3050
Fax Number	:

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	03/08/2016

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