Healthcare Provider Details

I. General information

NPI: 1891115945
Provider Name (Legal Business Name): BRIAN KENNETH WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 07/29/2023
Certification Date: 07/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 FRAYSER BLVD
MEMPHIS TN
38127-5977
US

IV. Provider business mailing address

4417 N 6TH ST
PHILADELPHIA PA
19140-2319
US

V. Phone/Fax

Practice location:
  • Phone: 901-842-3162
  • Fax: 901-842-2362
Mailing address:
  • Phone: 215-302-3600
  • Fax: 901-260-8590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD481351
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56026
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number56026
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD481351
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: