Healthcare Provider Details

I. General information

NPI: 1417994195
Provider Name (Legal Business Name): MARY WONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD
MAYFIELD HTS OH
44124-2203
US

IV. Provider business mailing address

2801 MARTIN LUTHER KING JR DR CR-11
CLEVELAND OH
44104-3815
US

V. Phone/Fax

Practice location:
  • Phone: 216-449-4500
  • Fax:
Mailing address:
  • Phone: 216-448-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.078204
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number35.078204
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: