Provider Demographics
NPI:1568476000
Name:WONG, KAM YUEN (DPM)
Entity type:Individual
Prefix:DR
First Name:KAM
Middle Name:YUEN
Last Name:WONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 30TH ST STE 403
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3305
Mailing Address - Country:US
Mailing Address - Phone:510-839-5219
Mailing Address - Fax:510-832-7340
Practice Address - Street 1:400 30TH ST SUITE 403
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3305
Practice Address - Country:US
Practice Address - Phone:510-839-5219
Practice Address - Fax:510-832-7340
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3387213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33870Medicaid
CA000E33870Medicare ID - Type Unspecified
CA000E33870Medicaid