Provider Demographics
NPI:1679790232
Name:CALVIN K. WONG, MD, PC
Entity type:Organization
Organization Name:CALVIN K. WONG, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-571-0606
Mailing Address - Street 1:5471 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1143
Mailing Address - Country:US
Mailing Address - Phone:858-571-0606
Mailing Address - Fax:858-571-1933
Practice Address - Street 1:5471 KEARNY VILLA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1143
Practice Address - Country:US
Practice Address - Phone:858-571-0606
Practice Address - Fax:858-571-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79819OtherMEDICARE GROUP NUMBER
WG79819COtherMEDICARE PROVIDER ID
G79819OtherMEDICARE PTAN
G60140Medicare UPIN