1821362344 NPI number — DR. IRENE WONG D.O.

Table of content: DR. IRENE WONG D.O. (NPI 1821362344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821362344 NPI number — DR. IRENE WONG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
IRENE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WONG
Provider Other First Name:
HOLIAM
Provider Other Middle Name:
IRENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821362344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-362-1735
Provider Business Mailing Address Fax Number:
973-290-7495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 UNION BLVD UNIT 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOTOWA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-938-5200
Provider Business Practice Location Address Fax Number:
973-938-5191
Provider Enumeration Date:
03/01/2012

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: 207Q00000X , with the licence number:  260111 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 25MB10295000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03480408 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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