1104036599 NPI number — I LANE WONG M.D.

Table of content: I LANE WONG M.D. (NPI 1104036599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104036599 NPI number — I LANE WONG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
I
Provider Middle Name:
LANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WONG
Provider Other First Name:
IRWIN
Provider Other Middle Name:
LANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104036599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 ALTON PKWY
Provider Second Line Business Mailing Address:
STE. 201
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92606-5024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-387-3888
Provider Business Mailing Address Fax Number:
949-387-3907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 ALTON PKWY
Provider Second Line Business Practice Location Address:
STE. 201
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92606-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-387-3888
Provider Business Practice Location Address Fax Number:
949-387-3907
Provider Enumeration Date:
05/23/2007

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: 174400000X , with the licence number:  G59317 , 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)

  • Identifier: G59317 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: INF1012 . This is a "MONARCH HEALTHCARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G9317 . This is a "BLUE SHIELD ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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