Provider Demographics
NPI:1972541266
Name:WONG, JAIR (MD)
Entity type:Individual
Prefix:DR
First Name:JAIR
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 1:906 S SUNSET AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3400
Mailing Address - Country:US
Mailing Address - Phone:626-962-9108
Mailing Address - Fax:626-960-7337
Practice Address - Street 1:906 S SUNSET AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3400
Practice Address - Country:US
Practice Address - Phone:626-962-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG75543FMedicaid
CAWG75543FMedicaid
CAF57702Medicare UPIN