Provider Demographics
NPI:1902057573
Name:SOLO INTERNAL MEDICINE
Entity Type:Organization
Organization Name:SOLO INTERNAL MEDICINE
Other - Org Name:SOLO INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:KAR TSUN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-768-1217
Mailing Address - Street 1:14568A MONO WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8858
Mailing Address - Country:US
Mailing Address - Phone:209-768-1217
Mailing Address - Fax:209-533-2061
Practice Address - Street 1:14568A MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8858
Practice Address - Country:US
Practice Address - Phone:209-768-1217
Practice Address - Fax:209-533-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-10-01
Deactivation Date:2008-08-21
Deactivation Code:
Reactivation Date:2008-10-01
Provider Licenses
StateLicense IDTaxonomies
CAG079608261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G796080Medicaid
G01744Medicare UPIN
ZZZ04982ZMedicare PIN