Provider Demographics
NPI:1164449625
Name:WONG, PHILLIP T (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 ATWELLS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-4144
Mailing Address - Country:US
Mailing Address - Phone:401-569-9488
Mailing Address - Fax:
Practice Address - Street 1:1109 ATWELLS AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-4144
Practice Address - Country:US
Practice Address - Phone:401-569-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00500111N00000X
MA2915111N00000X
NYX010778-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412382OtherBLUE CHIP
RI670397OtherUNITEDHEALTHCARE
RI31387OtherBCBSRI
RI000195502Medicare PIN
RI000195503Medicare PIN