Provider Demographics
NPI:1225045297
Name:WONG, KEVIN (MSPT,OCS, CAMT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MSPT,OCS, CAMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 71ST ST
Mailing Address - Street 2:SUITE CA
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3966
Mailing Address - Country:US
Mailing Address - Phone:718-874-6779
Mailing Address - Fax:718-651-6373
Practice Address - Street 1:4128 71ST ST
Practice Address - Street 2:CA
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3966
Practice Address - Country:US
Practice Address - Phone:718-874-6779
Practice Address - Fax:718-651-6373
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019209-12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07727GMedicare PIN
NY07727Medicare PIN