Basic Information
| Provider Information | |||||||||
| NPI: | 1841307535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803353 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | ARMC - MOB SUITE 308 | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 00G806640 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 00G806640 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 00G806640 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0079700 | 05 | CA | MEDICAID |