Provider Demographics
NPI:1902986920
Name:WONG, SHI-YIN (MD)
Entity Type:Individual
Prefix:MR
First Name:SHI-YIN
Middle Name:
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 1:407 W COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012
Mailing Address - Country:US
Mailing Address - Phone:213-626-3589
Mailing Address - Fax:213-626-7868
Practice Address - Street 1:407 W COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012
Practice Address - Country:US
Practice Address - Phone:213-626-3589
Practice Address - Fax:213-626-7868
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34772208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G347720Medicaid
CAE02624Medicare UPIN
CA00G347720Medicaid