Healthcare Provider Details

I. General information

NPI: 1336629542
Provider Name (Legal Business Name): BENJAMIN YIT WEI JONG MD, FRCS(C)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 POSEIDON BAY
WINNIPEG MANITOBA
R3M 3E4
CA

IV. Provider business mailing address

570 STRADBROOK AVENUE, APT 311
WINNIPEG MANITOBA
R3L 0S5
CA

V. Phone/Fax

Practice location:
  • Phone: 204-925-1550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberR-11209
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: