Healthcare Provider Details

I. General information

NPI: 1821052242
Provider Name (Legal Business Name): JASON H WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 CRESCENT ST
WALTHAM MA
02453-3475
US

IV. Provider business mailing address

PO BOX 211699
EAGAN MN
55121-3699
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax: 888-973-8821
Mailing address:
  • Phone: 866-849-0692
  • Fax: 888-973-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2021-02364
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD0041655
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberDR.0066357
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberTPME5081
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number35C.000339
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number86632
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number49117
License Number StateAL
# 8
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number63645
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberU1456
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number63516
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: