Healthcare Provider Details

I. General information

NPI: 1669826285
Provider Name (Legal Business Name): KENNETH RICHARD WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EAST 68TH STREET, MAILBOX 301 NY PRESBYTERIAN CORNELL- EMERGENCY MEDICINE RESIDENCY
NEW YORK CITY NY
10021
US

IV. Provider business mailing address

525 EAST 68TH STREET, MAILBOX 301 NY PRESBYTERIAN CORNELL- EMERGENCY MEDICINE RESIDENCY
NEW YORK CITY NY
10021
US

V. Phone/Fax

Practice location:
  • Phone: 949-903-0215
  • Fax:
Mailing address:
  • Phone: 949-903-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number910442318
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01084070A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-45699
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: