Provider Demographics
NPI:1124013404
Name:WONG, WALTER KHE TIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:KHE TIAN
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2424 S 90TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2455
Mailing Address - Country:US
Mailing Address - Phone:414-328-7646
Mailing Address - Fax:414-328-7699
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-7646
Practice Address - Fax:414-328-7699
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI240792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30632800Medicaid
E43958Medicare UPIN
WI30632800Medicaid