Provider Demographics
NPI:1427138619
Name:WONG, RICHARD MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
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 1:255 E WEBER AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2706
Mailing Address - Country:US
Mailing Address - Phone:209-466-5566
Mailing Address - Fax:209-466-0535
Practice Address - Street 1:255 E WEBER AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2706
Practice Address - Country:US
Practice Address - Phone:209-466-5566
Practice Address - Fax:209-466-0535
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62188207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A621880Medicaid
CABU678YMedicare PIN
CABU678ZMedicare PIN
CABU678XMedicare PIN
CA00A621880Medicaid
CABU678UMedicare PIN
CAH28780Medicare UPIN
CABU678WMedicare PIN
CA00A621880Medicare PIN
CA00A621881Medicare PIN