1902044951 NPI number — DR. DEBORAH JEAN LEE WONG M.D., PH.D.

Table of content: DR. DEBORAH JEAN LEE WONG M.D., PH.D. (NPI 1902044951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902044951 NPI number — DR. DEBORAH JEAN LEE WONG M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
DEBORAH
Provider Middle Name:
JEAN LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902044951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90404-2429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEDICAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 550
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-794-4955
Provider Business Practice Location Address Fax Number:
310-443-0477
Provider Enumeration Date:
01/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A101243 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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