Healthcare Provider Details

I. General information

NPI: 1275997181
Provider Name (Legal Business Name): GEORGE RAYMOND WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 PEACHTREE RD NW STE 505
ATLANTA GA
30309-5219
US

IV. Provider business mailing address

1984 PEACHTREE RD NW STE 505
ATLANTA GA
30309-5219
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-1409
  • Fax:
Mailing address:
  • Phone: 404-352-1409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number90629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: