Provider Demographics
NPI:1053304204
Name:MIN, WONHONG DAVID (MD)
Entity Type:Individual
Prefix:
First Name:WONHONG
Middle Name:DAVID
Last Name:MIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 S 700 E STE 300A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1496
Mailing Address - Country:US
Mailing Address - Phone:801-261-4988
Mailing Address - Fax:801-269-9425
Practice Address - Street 1:3838 S 700 E STE 300A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1496
Practice Address - Country:US
Practice Address - Phone:801-261-4988
Practice Address - Fax:801-269-9425
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19641207T00000X
WY8937A207T00000X
UT7915443-1205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1000177430AMedicaid
OKH20964Medicare UPIN
OK242622902Medicare PIN