Provider Demographics
NPI:1992919823
Name:WONG, REGINA FUNG GUEN (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:FUNG GUEN
Last Name:WONG
Suffix:
Gender:F
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:PO BOX 241011
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-9511
Mailing Address - Country:US
Mailing Address - Phone:209-333-3121
Mailing Address - Fax:209-333-3008
Practice Address - Street 1:2415 W VINE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3731
Practice Address - Country:US
Practice Address - Phone:209-333-3135
Practice Address - Fax:209-333-3008
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics