Healthcare Provider Details

I. General information

NPI: 1609619600
Provider Name (Legal Business Name): DAVID WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 CLARKSON AVE
BROOKLYN NY
11203-2125
US

IV. Provider business mailing address

1722 TROUTMAN ST # 1
RIDGEWOOD NY
11385-1015
US

V. Phone/Fax

Practice location:
  • Phone: 718-221-7499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number694447-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: