Provider Demographics
NPI:1962400531
Name:WONG, CALVIN K (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:K
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:444 WEST C STREET
Mailing Address - Street 2:SUITE 185
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:619-232-6262
Mailing Address - Fax:619-232-6012
Practice Address - Street 1:444 WEST C STREET
Practice Address - Street 2:SUITE 185
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101
Practice Address - Country:US
Practice Address - Phone:619-232-6262
Practice Address - Fax:619-232-6012
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG79819207QS0010X, 207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G60140Medicare UPIN
CAWG79819CMedicare ID - Type Unspecified