Healthcare Provider Details

I. General information

NPI: 1760479323
Provider Name (Legal Business Name): JACQUELINE W WONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 HILDEBRAND LN NE SUITE 235
BAINBRIDGE ISLAND WA
98110-2877
US

IV. Provider business mailing address

945 HILDEBRAND LN NE SUITE 235
BAINBRIDGE ISLAND WA
98110-2877
US

V. Phone/Fax

Practice location:
  • Phone: 360-621-9970
  • Fax: 206-257-0983
Mailing address:
  • Phone: 360-621-9970
  • Fax: 206-257-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00039827
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: