MEDICARE: CRISTY A 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	208000000X	Pediatrics Physician	ME105408	FL
2	208D00000X	General Practice Physician	ME105408	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639302169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTY A WONG MD

Provider Business Mailing Address
First Line	:	PO BOX 191
Second Line	:	PROVIDER ENROLLMENT DEPARTMENT
City	:	ROCKLAND
State	:	DE
Zip	:	19732-0191
Country	:	US
Telephone Number	:	302-651-4488
Fax Number	:	302-651-4945

Provider Business Practice Location Address
First Line	:	521 WEST STATE ROAD 434, SUITE 101 PEDIATRIC
Second Line	:	& ADOLESCENT MED OF SEMINOLE, IIN ASSOC WITH NEMOURS
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4952
Country	:	US
Telephone Number	:	407-830-5437
Fax Number	:	407-830-4907

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

Provider Enumeration Date	:	09/01/2009
Last Update Date	:	10/09/2014

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Directions to “ CRISTY A WONG MD” Practice Location

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