MEDICARE: DR. WALTER KHE TIAN WONG MD

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	2084N0400X	Neurology Physician	24079	WI

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	:	1124013404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER KHE TIAN WONG MD

Provider Business Mailing Address
First Line	:	2424 S 90TH ST
Second Line	:	SUITE 202
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2455
Country	:	US
Telephone Number	:	414-328-7646
Fax Number	:	414-328-7699

Provider Business Practice Location Address
First Line	:	2424 S 90TH ST
Second Line	:	SUITE 202
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2455
Country	:	US
Telephone Number	:	414-328-7646
Fax Number	:	414-328-7699

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	09/15/2009

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