Provider Demographics
NPI:1679559157
Name:WONG, EDWARD TZE (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:TZE
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 1:44725 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3048
Mailing Address - Country:US
Mailing Address - Phone:661-945-1874
Mailing Address - Fax:661-945-2584
Practice Address - Street 1:44725 10TH ST WEST #250
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3048
Practice Address - Country:US
Practice Address - Phone:661-945-1874
Practice Address - Fax:661-945-2584
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63865207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG638650Medicaid
CAG63865Medicare ID - Type Unspecified
CAE32628Medicare UPIN