Provider Demographics
NPI:1275552713
Name:WONG, SUSAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:T
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 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 604
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-5982
Mailing Address - Fax:585-756-0169
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 604
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-5982
Practice Address - Fax:585-756-0169
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179629207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5216039OtherAETNA
NY2222OtherBLUE SHIELD GROUP
NYMDC626OtherPREFERRED CARE
NY000916798001OtherBS WNY/HEALTHNOW
NY00040026702OtherUNIVERA
NY00372225Medicaid
NY050063381OtherRAILROAD MEDICARE
NY01575442Medicaid
NYG0189393590OtherBLUE CHOICE GROUP
NYP010179629OtherBLUE CHOICE
NYBB2322Medicare ID - Type UnspecifiedMEDICARE
NY00372225Medicaid
NYMDC626OtherPREFERRED CARE