Provider Demographics
NPI:1205196441
Name:WONG, GENEVIEVE (MD)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
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 1:3231 EUCLID AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4603
Mailing Address - Country:US
Mailing Address - Phone:708-783-2000
Mailing Address - Fax:708-783-3656
Practice Address - Street 1:3231 EUCLID AVE FL 5
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-4603
Practice Address - Country:US
Practice Address - Phone:708-783-2000
Practice Address - Fax:708-783-3656
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-061169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine