1255364857 NPI number — FONG JAMES WONG,M.D,P.A

Table of content: (NPI 1255364857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255364857 NPI number — FONG JAMES WONG,M.D,P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FONG JAMES WONG,M.D,P.A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255364857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1740 S.E 18TH STREET
Provider Second Line Business Mailing Address:
UNIT 801
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34471-5447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-351-8877
Provider Business Mailing Address Fax Number:
352-351-8867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 S.E 18TH STREET
Provider Second Line Business Practice Location Address:
UNIT 801
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-5447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-351-8877
Provider Business Practice Location Address Fax Number:
352-351-8867
Provider Enumeration Date:
07/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
FONG
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-351-8877

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  ME76024 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)