Provider Demographics
NPI:1194734715
Name:WONG, IRA G (MD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:G
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1635 DIVISADERO ST
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:95 KIRKHAM ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0001
Practice Address - Country:US
Practice Address - Phone:415-476-1442
Practice Address - Fax:415-502-2521
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG27700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G277000Medicaid
CAA43456Medicare UPIN
CA00G277000Medicare PIN