Provider Demographics
NPI:1164442703
Name:WONG, WAYNE D (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:D
Last Name:WONG
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 1:4201 WINFIELD RD FL 3
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 E BRUSH HILL RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:331-221-8952
Practice Address - Fax:331-221-3782
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123199207R00000X, 208M00000X
IL036-123199207R00000X
CAA89789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A897890Medicaid
00A897890OtherBLUE SHIELD OF CA
00A897890OtherBLUE SHIELD OF CA