Provider Demographics
NPI:1780625053
Name:WONG, BRADLEY DAIJUNG (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAIJUNG
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 1:550 S BERETANIA ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2496
Mailing Address - Country:US
Mailing Address - Phone:808-528-4144
Mailing Address - Fax:808-525-6868
Practice Address - Street 1:550 S BERETANIA ST
Practice Address - Street 2:SUITE 501
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2496
Practice Address - Country:US
Practice Address - Phone:808-528-4144
Practice Address - Fax:808-525-6868
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2954208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04555001Medicaid
HIH0000BDRTLMedicare ID - Type Unspecified
HI04555001Medicaid