Provider Demographics
NPI:1699778399
Name:WONG, DOUGLAS S (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:S
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 1:1303 E HERNDON AVE
Mailing Address - Street 2:SUITE 431
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3309
Mailing Address - Country:US
Mailing Address - Phone:559-450-3889
Mailing Address - Fax:559-450-7473
Practice Address - Street 1:7130 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3347
Practice Address - Country:US
Practice Address - Phone:559-450-5500
Practice Address - Fax:559-450-7473
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45487174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G454870Medicaid
CAE27929Medicare UPIN
CA00G454870Medicaid
CA920002867Medicare PIN