Provider Demographics
NPI:1275055436
Name:WONG, TAI YUEN (MB,CHB)
Entity Type:Individual
Prefix:DR
First Name:TAI
Middle Name:YUEN
Last Name:WONG
Suffix:
Gender:M
Credentials:MB,CHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MARKET ST STE 2820
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2936
Mailing Address - Country:US
Mailing Address - Phone:215-704-7177
Mailing Address - Fax:
Practice Address - Street 1:1101 MARKET ST STE 2820
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2936
Practice Address - Country:US
Practice Address - Phone:215-592-9750
Practice Address - Fax:215-592-0129
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004382207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology