Provider Demographics
NPI:1063537934
Name:WONG, GLENN (DO)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:831-479-6603
Mailing Address - Fax:831-458-6293
Practice Address - Street 1:2850 COMMERCIAL XING
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1702
Practice Address - Country:US
Practice Address - Phone:831-460-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10095207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology