Basic Information
| Provider Information | |||||||||
| NPI: | 1104082098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 BAYLEAF LN | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926201261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497011133 | ||||||||
| FaxNumber: | 8186387814 | ||||||||
| Practice Location | |||||||||
| Address1: | 10900 WARNER AVE | ||||||||
| Address2: | SUITE #101 A | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927083846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146981270 | ||||||||
| FaxNumber: | 7149627261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20A6336 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0020A6336 | 05 | CA | MEDICAID |