=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144615238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AN-KWOK WONG M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 11/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 MICHAEL ST NE STE 205-M
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-712-2973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5213 S ALSTON AVE
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27713-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-620-4855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 2021-00697
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------