Provider Demographics
NPI:1699710160
Name:JOANNA M. WONG, M.D. A MEDICAL CORP.
Entity type:Organization
Organization Name:JOANNA M. WONG, M.D. A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-939-7850
Mailing Address - Street 1:855 MANHATTAN BEACH BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4965
Mailing Address - Country:US
Mailing Address - Phone:310-939-7850
Mailing Address - Fax:310-939-7851
Practice Address - Street 1:855 MANHATTAN BEACH BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4965
Practice Address - Country:US
Practice Address - Phone:310-939-7850
Practice Address - Fax:310-939-7851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG46405OtherMEDICAL LICENSE