Provider Demographics
NPI:1780641704
Name:WONG, JASON T (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24411 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3651
Mailing Address - Country:US
Mailing Address - Phone:310-923-4556
Mailing Address - Fax:
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:SUITE 350
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3651
Practice Address - Country:US
Practice Address - Phone:310-923-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227262208600000X
CAA113420208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2120917Medicaid
MA2120917Medicaid
MAHX4537Medicare PIN