Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 000000A50734 | CA |
NPI | 1487748752 |
---|---|
Provider Name | Brian Wong |
First Address | Los Angeles, CA 90051-3700 |
Second Address | Orange, CA 92868 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 18/12/2007 |