MEDICARE: GRACE WONG MD INC

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	A96700	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053504902	OTHER	CA	TYPE 1 NPI

General Provider Information

NPI Number	:	1659648384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WONG MD INC

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	:	626-347-9074
Fax Number	:	818-509-5939

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	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GRACE WONG
Credential	:	M.D.
Telephone Number	:	626-347-9074

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	12/28/2023

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