Provider Demographics
NPI:1215106448
Name:WONG, KELLY TIM TIM (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:TIM TIM
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:500 N GARFIELD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1242
Mailing Address - Country:US
Mailing Address - Phone:626-288-3828
Mailing Address - Fax:626-573-8513
Practice Address - Street 1:500 N GARFIELD AVE STE 105
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1242
Practice Address - Country:US
Practice Address - Phone:626-288-3828
Practice Address - Fax:626-573-8513
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA20A10595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program