Provider Demographics
NPI:1316926488
Name:WONG, BRIAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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 1:3701 SKYPARK DR
Mailing Address - Street 2:#200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4753
Mailing Address - Country:US
Mailing Address - Phone:310-378-8900
Mailing Address - Fax:310-791-0786
Practice Address - Street 1:3701 SKYPARK DR
Practice Address - Street 2:#200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4753
Practice Address - Country:US
Practice Address - Phone:310-378-8900
Practice Address - Fax:310-791-0786
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA93255207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G472900Medicaid
CA1316926488Medicaid
CA00G472900Medicaid
E48081Medicare UPIN
CA1316926488Medicaid
CAWG47590BMedicare PIN