Healthcare Provider Details

I. General information

NPI: 1336588482
Provider Name (Legal Business Name): BRIAN WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102
US

IV. Provider business mailing address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

V. Phone/Fax

Practice location:
  • Phone: 605-522-4429
  • Fax:
Mailing address:
  • Phone:
  • Fax: 401-444-6858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberLP03175
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: