Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | G73118 | CA |
N | 208000000X | Pediatrician | G73118 | CA |
NPI | 1134199946 |
---|---|
Provider Name | Dr. Derek Alan Wong |
First Address | Los Angeles, CA 90095-1732 |
Second Address | Los Angeles, CA 90095-1732 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2006 |
Last Update Date | 09/01/2015 |