MEDICARE: DR. CHARLES W WONG DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2041	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063401248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES W WONG DO

Provider Business Mailing Address
First Line	:	310 S MAIN ST
Second Line	:	PO BOX 148
City	:	HARTFORD
State	:	KY
Zip	:	42347-1129
Country	:	US
Telephone Number	:	270-298-9136
Fax Number	:	270-298-9039

Provider Business Practice Location Address
First Line	:	310 S MAIN ST
Second Line	:
City	:	HARTFORD
State	:	KY
Zip	:	42347-1129
Country	:	US
Telephone Number	:	270-298-9136
Fax Number	:	270-298-9039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	01/09/2010

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