Healthcare Provider Details

I. General information

NPI: 1942279518
Provider Name (Legal Business Name): ALBERT KINTIM WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KINTIM ALBERT WONG M.D.

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 KNOLL NORTH DR STE 490
COLUMBIA MD
21045-2380
US

IV. Provider business mailing address

5500 KNOLL NORTH DR STE 490
COLUMBIA MD
21045-2380
US

V. Phone/Fax

Practice location:
  • Phone: 410-964-1200
  • Fax: 410-964-1002
Mailing address:
  • Phone: 410-964-1200
  • Fax: 410-964-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberD0025635
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0025635
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: