MEDICARE: SPROUT PEDIATRICS, 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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1962693754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPROUT PEDIATRICS, INC.

Provider Business Mailing Address
First Line	:	1666 MEDICAL CENTER DR
Second Line	:	SUITE 4
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1257
Country	:	US
Telephone Number	:	909-887-7050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1666 MEDICAL CENTER DR
Second Line	:	SUITE 4
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1257
Country	:	US
Telephone Number	:	909-887-7050
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WEBSTER A WONG
Credential	:	M.D.
Telephone Number	:	909-580-6315

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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