Provider Demographics
NPI:1770928483
Name:WONG, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N MOUNTAIN AVE # E122
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1128
Mailing Address - Country:US
Mailing Address - Phone:909-623-4484
Mailing Address - Fax:909-623-4485
Practice Address - Street 1:1520 N MOUNTAIN AVE # E122
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1128
Practice Address - Country:US
Practice Address - Phone:909-623-4484
Practice Address - Fax:909-623-4485
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5235213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery