Healthcare Provider Details

I. General information

NPI: 1598758120
Provider Name (Legal Business Name): JOSEPH KENNETH WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3091 KIRBY WHITTEN RD
BARTLETT TN
38134-2822
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5800
US

V. Phone/Fax

Practice location:
  • Phone: 901-752-6963
  • Fax: 901-751-5540
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD20088
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: