MEDICARE: IAN 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	2085R0202X	Diagnostic Radiology Physician	11012559A	IN

General Provider Information

NPI Number	:	1366604134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN WONG MD

Provider Business Mailing Address
First Line	:	924 FAYETTE ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	924 FAYETTE ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3019
Country	:	US
Telephone Number	:	317-687-9664
Fax Number	:

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

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/01/2008

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