Provider Demographics
NPI:1194284166
Name:WONG, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845996
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-5996
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:
Practice Address - Street 1:8851 CENTER DR STE 501
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3033
Practice Address - Country:US
Practice Address - Phone:619-697-2456
Practice Address - Fax:858-429-7930
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA195509207R00000X, 208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine