Provider Demographics
NPI:1134139629
Name:WONG, GUSTAVO C (RDN, CDE, EP-C)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:RDN, CDE, EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1384
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1050
Mailing Address - Country:US
Mailing Address - Phone:760-636-1408
Mailing Address - Fax:
Practice Address - Street 1:1515 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262
Practice Address - Country:US
Practice Address - Phone:800-720-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered