Provider Demographics
NPI:1093704769
Name:WONG, ANN MARIE DEVERAS (MD)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:DEVERAS
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 1:375 NE 54TH ST STE 7
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2966
Mailing Address - Country:US
Mailing Address - Phone:786-842-7001
Mailing Address - Fax:786-410-9200
Practice Address - Street 1:1801 NE 123RD ST
Practice Address - Street 2:SUITE 414
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2817
Practice Address - Country:US
Practice Address - Phone:305-981-0600
Practice Address - Fax:305-981-2700
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204659208000000X
FLME 108078208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002812400Medicaid