Provider Demographics
NPI:1548641939
Name:TONY LEE WONG, MD., INC.
Entity type:Organization
Organization Name:TONY LEE WONG, MD., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-992-5300
Mailing Address - Street 1:1800 SULLIVAN AVE RM 104
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2227
Mailing Address - Country:US
Mailing Address - Phone:650-992-5300
Mailing Address - Fax:650-992-5395
Practice Address - Street 1:1800 SULLIVAN AVE RM 104
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2227
Practice Address - Country:US
Practice Address - Phone:650-992-5300
Practice Address - Fax:650-992-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051262261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF84691Medicare UPIN