1912191404 NPI number — DOROTHY L. P. WONG, MD, LLC

Table of content: (NPI 1912191404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912191404 NPI number — DOROTHY L. P. WONG, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOROTHY L. P. WONG, MD, LLC
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:
1912191404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 W 24TH ST
Provider Second Line Business Mailing Address:
SUITE 26
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-8366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-344-5455
Provider Business Mailing Address Fax Number:
928-344-5465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 W 24TH ST
Provider Second Line Business Practice Location Address:
SUITE 26
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-8366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-344-5455
Provider Business Practice Location Address Fax Number:
928-344-5465
Provider Enumeration Date:
08/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
LAI PING
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-344-5455

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  22877 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110180845 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 330085 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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