Provider Demographics
NPI:1164460937
Name:WONG, ANTONIO H (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:H
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 1:501 NW 179TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2807
Mailing Address - Country:US
Mailing Address - Phone:954-442-2828
Mailing Address - Fax:954-442-3366
Practice Address - Street 1:501 NW 179TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2807
Practice Address - Country:US
Practice Address - Phone:954-442-2828
Practice Address - Fax:954-442-3366
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373222300Medicaid
FL23095Medicare PIN