Provider Demographics
NPI:1144250994
Name:WONG, SUSIE YIN-PENG (MD)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:YIN-PENG
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18617 GALE AVE
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1342
Mailing Address - Country:US
Mailing Address - Phone:626-912-1871
Mailing Address - Fax:626-912-6766
Practice Address - Street 1:18617 GALE AVE
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1342
Practice Address - Country:US
Practice Address - Phone:626-912-1871
Practice Address - Fax:626-912-6766
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC042888207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C428880Medicaid
CAC42888Medicare ID - Type Unspecified
CA00C428880Medicaid