Healthcare Provider Details

I. General information

NPI: 1497114268
Provider Name (Legal Business Name): ALICE WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 DAVIS AVE
POUGHKEEPSIE NY
12603-2416
US

IV. Provider business mailing address

27 DAVIS AVE
POUGHKEEPSIE NY
12603-2416
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-1025
  • Fax: 845-454-5881
Mailing address:
  • Phone: 845-454-1025
  • Fax: 845-454-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number20A18437
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number312256
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: