Healthcare Provider Details

I. General information

NPI: 1750320750
Provider Name (Legal Business Name): MING T WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 HARVARD AVE SUITE 2
ALLSTON MA
02134-2829
US

IV. Provider business mailing address

196 HARVARD AVE SUITE 2
ALLSTON MA
02134-2829
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-5805
  • Fax:
Mailing address:
  • Phone: 617-254-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48872
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: