Provider Demographics
NPI:1538149919
Name:WU, KONG-TAY (MD)
Entity type:Individual
Prefix:
First Name:KONG-TAY
Middle Name:
Last Name:WU
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 1:1818 N ORANGE GROVE AVE
Mailing Address - Street 2:#200
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767
Mailing Address - Country:US
Mailing Address - Phone:909-622-6433
Mailing Address - Fax:909-469-2524
Practice Address - Street 1:1818 N ORANGE GROVE AVE
Practice Address - Street 2:#200
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-622-6433
Practice Address - Fax:909-469-2524
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A305530Medicaid