Healthcare Provider Details

I. General information

NPI: 1144615238
Provider Name (Legal Business Name): AN-KWOK WONG M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 MICHAEL ST NE STE 205-M
ATLANTA GA
30322-1007
US

IV. Provider business mailing address

5213 S ALSTON AVE
DURHAM NC
27713-4430
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-2973
  • Fax:
Mailing address:
  • Phone: 919-620-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2021-00697
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: