Healthcare Provider Details

I. General information

NPI: 1790422343
Provider Name (Legal Business Name): MATTHEW VEN-FUNG WONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 E 14 MILE RD
BIRMINGHAM MI
48009-7256
US

IV. Provider business mailing address

2055 E 14 MILE RD
BIRMINGHAM MI
48009-7256
US

V. Phone/Fax

Practice location:
  • Phone: 248-645-1740
  • Fax: 248-645-5304
Mailing address:
  • Phone: 248-645-1740
  • Fax: 248-645-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5151015929
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: