Healthcare Provider Details

I. General information

NPI: 1487641957
Provider Name (Legal Business Name): LESLIE P WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LESLIE PAK YIN WONG MD

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E RIDGE RD STE 20
ROCHESTER NY
14621-1239
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD00043067
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberC54492
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number12745135-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number328842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: