Healthcare Provider Details

I. General information

NPI: 1639581093
Provider Name (Legal Business Name): MARTHA SHIH WONG MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 GRAND CONCOURSE SUITE 1C
BRONX NY
10451-2814
US

IV. Provider business mailing address

127 BREWSTER RD
SCARSDALE NY
10583-2003
US

V. Phone/Fax

Practice location:
  • Phone: 718-665-7384
  • Fax: 718-665-5335
Mailing address:
  • Phone: 917-969-2783
  • Fax: 718-665-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number113881
License Number StateNY

VIII. Authorized Official

Name: MARTHA SHIH WONG
Title or Position: OWNER
Credential: M.D.
Phone: 917-969-2783