Healthcare Provider Details

I. General information

NPI: 1194136820
Provider Name (Legal Business Name): ANGELICA WONG DESPAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax: 215-590-2180
Mailing address:
  • Phone: 215-590-1000
  • Fax: 215-590-2180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT0196
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD045994
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD480961
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberT0196
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: