MEDICARE: LINA LY WONG D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	12219	CA

General Provider Information

NPI Number	:	1417112392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINA LY WONG D.O.

Provider Business Mailing Address
First Line	:	3006 SAN GABRIEL BLVD
Second Line	:
City	:	ROSEMEAD
State	:	CA
Zip	:	91770-2536
Country	:	US
Telephone Number	:	626-773-8900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3006 SAN GABRIEL BLVD
Second Line	:
City	:	ROSEMEAD
State	:	CA
Zip	:	91770-2536
Country	:	US
Telephone Number	:	626-773-8900
Fax Number	:

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

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	01/08/2015

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Directions to “ LINA LY WONG D.O.” Practice Location

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