Provider Demographics
NPI:1205867975
Name:DR WONG, MED-PED, P.A.
Entity Type:Organization
Organization Name:DR WONG, MED-PED, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:ROBERTA
Authorized Official - Last Name:WONGCHANTARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-823-1111
Mailing Address - Street 1:461 7TH AVE S
Mailing Address - Street 2:DR WONG, MED-PED, P.A.
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4818
Mailing Address - Country:US
Mailing Address - Phone:727-823-1111
Mailing Address - Fax:727-823-4153
Practice Address - Street 1:461 7TH AVE S
Practice Address - Street 2:DR WONG, MED-PED, P.A.
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4818
Practice Address - Country:US
Practice Address - Phone:727-823-1111
Practice Address - Fax:727-823-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076151261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care