| Doctor Name: | DR. JACK K WONG |
| NPI Number: | 1790725539 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 34719 |
| Business Practice Address: | 19 Myrtle St Medford, OR - 975047337 |
| Business Phone Number: | 5417733863 |
| Business Fax Number: | 5417762892 |
| Mailing Address: | 19 Myrtle St, MEDFORD |
| State: | OR |
| Postal Code: | 975047337 |
| Phone Number: | 5417733863 |
| Fax Number: | 5417762892 |
| NPI Enumeration Date: | 06/08/2006 |
| NPI Last Update Date: | 04/10/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 34719 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | AZ |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |