Healthcare Provider Details

I. General information

NPI: 1508844499
Provider Name (Legal Business Name): LAWRENCE MICHAEL WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

V. Phone/Fax

Practice location:
  • Phone: 954-985-5921
  • Fax: 954-985-3471
Mailing address:
  • Phone: 954-985-5921
  • Fax: 954-985-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME62506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: