Provider Demographics
NPI:1144303801
Name:WONG, STEPHEN KENNETH (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KENNETH
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 1:3 PARK CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-8341
Mailing Address - Country:US
Mailing Address - Phone:916-761-8635
Mailing Address - Fax:
Practice Address - Street 1:5771 GREENBACK LN
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2013
Practice Address - Country:US
Practice Address - Phone:916-761-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40039207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A400390Medicaid
CA00A400390Medicaid
CA00A400390Medicare ID - Type Unspecified