Provider Demographics
NPI:1235354887
Name:BERT KW WONG MD LLC
Entity Type:Organization
Organization Name:BERT KW WONG MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:KW
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-526-0686
Mailing Address - Street 1:2228 LILIHA ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1646
Mailing Address - Country:US
Mailing Address - Phone:808-526-0686
Mailing Address - Fax:808-526-0688
Practice Address - Street 1:2228 LILIHA ST
Practice Address - Street 2:SUITE 305
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1646
Practice Address - Country:US
Practice Address - Phone:808-526-0686
Practice Address - Fax:808-526-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3694207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17149OtherHMSA
HI03062302Medicaid
C17149OtherHMSA
101009Medicare ID - Type Unspecified