Provider Demographics
NPI:1053706267
Name:WONG, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WONG
Suffix:
Gender:
Credentials:MD
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Mailing Address - Street 1:630 S RAYMOND AVE UNIT 310
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3206
Mailing Address - Country:US
Mailing Address - Phone:626-598-3770
Mailing Address - Fax:626-598-3797
Practice Address - Street 1:425 FAIR OAKS AVE
Practice Address - Street 2:STE 175
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030
Practice Address - Country:US
Practice Address - Phone:626-598-3770
Practice Address - Fax:626-598-3797
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAD39668702080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities