Provider Demographics
NPI:1073394136
Name:WONG, TONY (DPT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 N BROADWAY ST APT 953
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5270
Mailing Address - Country:US
Mailing Address - Phone:917-302-5339
Mailing Address - Fax:
Practice Address - Street 1:5214 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4624
Practice Address - Country:US
Practice Address - Phone:773-649-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist