Provider Demographics
NPI:1073019014
Name:WONG, THERESA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BURLEYSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3181
Mailing Address - Country:US
Mailing Address - Phone:706-278-4640
Mailing Address - Fax:706-275-6599
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3181
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:706-275-6599
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA92790207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program