1639581093 NPI number — MARTHA SHIH WONG MD

Table of content: (NPI 1639581093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639581093 NPI number — MARTHA SHIH WONG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTHA SHIH WONG MD
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:
1639581093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 BREWSTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCARSDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10583-2003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-969-2783
Provider Business Mailing Address Fax Number:
718-665-5335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 GRAND CONCOURSE
Provider Second Line Business Practice Location Address:
SUITE 1C
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10451-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-665-7384
Provider Business Practice Location Address Fax Number:
718-665-5335
Provider Enumeration Date:
05/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
SHIH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
917-969-2783

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  113881 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00208131 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113881 . This is a "NYS LICENSE" identifier . This identifiers is of the category "OTHER".




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