Provider Demographics
NPI:1962436428
Name:WONG, KIN (MD)
Entity type:Individual
Prefix:DR
First Name:KIN
Middle Name:
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 1:709 N HILL ST
Mailing Address - Street 2:#8
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012
Mailing Address - Country:US
Mailing Address - Phone:213-628-3300
Mailing Address - Fax:213-625-2940
Practice Address - Street 1:709 N HILL ST STE 8
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2352
Practice Address - Country:US
Practice Address - Phone:213-628-3300
Practice Address - Fax:213-625-2940
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX72580Medicaid
20A7258Medicare PIN