Healthcare Provider Details

I. General information

NPI: 1447305594
Provider Name (Legal Business Name): DAVID WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 VASSAR DR NE
ALBUQUERQUE NM
87106-2725
US

IV. Provider business mailing address

801 VASSAR DR NE
ALBUQUERQUE NM
87106-2725
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-4000
  • Fax: 505-248-4088
Mailing address:
  • Phone: 505-248-4000
  • Fax: 505-248-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD23548
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2007-0686
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: