Provider Demographics
NPI:1285935585
Name:WONG, JERRY THWIN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:THWIN
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 EAST DUARTE ROAD
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-256-4673
Mailing Address - Fax:626-301-8463
Practice Address - Street 1:1500 EAST DUARTE ROAD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:626-301-8463
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA163242207ZP0102X
CA136242207ZH0000X
NY288002207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology