Provider Demographics
NPI:1386977288
Name:WONG, GREGORY KELII (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:KELII
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 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-4099
Mailing Address - Fax:714-509-3301
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-4099
Practice Address - Fax:714-509-3301
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN77652080P0206X
CAA1249392080P0206X
NC159602390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program