1457424392 NPI number — EDISON WONG M.D.

Table of content: EDISON WONG M.D. (NPI 1457424392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457424392 NPI number — EDISON WONG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
EDISON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1457424392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
668 N ORLANDO AVE STE 1010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-4460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-644-0101
Provider Business Mailing Address Fax Number:
321-441-1559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
668 N ORLANDO AVE STE 1010
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAITLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32751-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-644-0101
Provider Business Practice Location Address Fax Number:
321-441-1559
Provider Enumeration Date:
11/16/2006

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: 2081P2900X , with the licence number:  040751 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: 81293 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J31343 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 30555 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 80911 . This is a "HARV PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 758575 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 972848 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3139875 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00132480 . This is a "MR RR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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