1104885987 NPI number — DR. VIVIEN C WONG MD, MPH

Table of content: DR. VIVIEN C WONG MD, MPH (NPI 1104885987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104885987 NPI number — DR. VIVIEN C WONG MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
VIVIEN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
F

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:
1104885987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1481 S KING ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96814-2601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-949-0091
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1481 S KING ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-949-0091
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2006

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: 2085R0202X , with the licence number:  MD12827 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: B006 . This is a "TRICARE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 1658244 . This is a "UHA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 55076601 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD12827 . This is a "QHC" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 0000246355 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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