MEDICARE: KIN S WONG D.O.

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	207R00000X	Internal Medicine Physician	20A8177	CA
2	261QU0200X	Urgent Care Clinic/Center	K9458	TX
3	207R00000X	Internal Medicine Physician	K9458	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0063LS	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1760440531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIN S WONG D.O.

Provider Business Mailing Address
First Line	:	1921 S MAIN ST
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-5120
Country	:	US
Telephone Number	:	817-337-8884
Fax Number	:	817-337-8075

Provider Business Practice Location Address
First Line	:	1921 S MAIN ST
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-5120
Country	:	US
Telephone Number	:	817-337-8884
Fax Number	:	817-337-8075

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

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	02/06/2026

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Directions to “ KIN S WONG D.O.” Practice Location

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