1649244674 NPI number — DR. LYNDON CHARLES WONG OD

Table of content: DR. LYNDON CHARLES WONG OD (NPI 1649244674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649244674 NPI number — DR. LYNDON CHARLES WONG OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
LYNDON
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1649244674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD STE 520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-3970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5330B SOUTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28217-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-525-9802
Provider Business Practice Location Address Fax Number:
704-523-2862
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  VUT 005474 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2252 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00244528 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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