Provider Demographics
NPI:1104082098
Name:WONG, MICHAEL HENRY (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HENRY
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 BAYLEAF LN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1261
Mailing Address - Country:US
Mailing Address - Phone:949-701-1133
Mailing Address - Fax:818-638-7814
Practice Address - Street 1:10900 WARNER AVE
Practice Address - Street 2:SUITE #101 A
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3846
Practice Address - Country:US
Practice Address - Phone:714-698-1270
Practice Address - Fax:714-962-7261
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6336207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0020A6336Medicaid
CABH953ZMedicare PIN
CAG05799Medicare UPIN