Provider Demographics
NPI:1780771162
Name:WONG, MICHAEL ALAN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
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 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:SUITE 12B
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-588-7110
Mailing Address - Fax:949-588-6985
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:SUITE 12B
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-588-7110
Practice Address - Fax:949-588-6985
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG062105207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G62105Medicare ID - Type Unspecified
E28280Medicare UPIN