Healthcare Provider Details

I. General information

NPI: 1104033281
Provider Name (Legal Business Name): MATTHEW H. WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 BANNOCK ST FL 5
DENVER CO
80204-4506
US

IV. Provider business mailing address

1802 TIFFANY PL
GREENSBORO NC
27408-3112
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-6170
  • Fax: 303-602-6190
Mailing address:
  • Phone: 363-413-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDR.0067632
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME139159
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101248367
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number2010-02130
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number2010-02130
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2010-02130
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: