Healthcare Provider Details

I. General information

NPI: 1124073226
Provider Name (Legal Business Name): DOMINC K.H. WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S TELSHOR BLVD STE 104
LAS CRUCES NM
88011-9148
US

IV. Provider business mailing address

2525 S TELSHOR BLVD STE 104
LAS CRUCES NM
88011-9148
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-7697
  • Fax:
Mailing address:
  • Phone: 505-522-7697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2002-0337
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: