Healthcare Provider Details

I. General information

NPI: 1275553877
Provider Name (Legal Business Name): JEAN-MARC C WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVENUE
BOULDER CO
80304-2296
US

IV. Provider business mailing address

1333 IRIS AVENUE
BOULDER CO
80304-2296
US

V. Phone/Fax

Practice location:
  • Phone: 720-406-3621
  • Fax: 720-406-3603
Mailing address:
  • Phone: 720-406-3621
  • Fax: 720-406-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34549
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: