Healthcare Provider Details

I. General information

NPI: 1336431071
Provider Name (Legal Business Name): BRIAN WOONGKI HONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 05/03/2020
Certification Date: 05/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MILL ST
NEW LONDON WI
54961-2155
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 920-531-2400
  • Fax: 920-531-2450
Mailing address:
  • Phone: 920-725-4527
  • Fax: 920-729-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPENDING
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number65808
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: