Provider Demographics
NPI:1275699274
Name:WONG, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W 38TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1167
Mailing Address - Country:US
Mailing Address - Phone:512-451-0103
Mailing Address - Fax:512-451-2741
Practice Address - Street 1:801 W 38TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1167
Practice Address - Country:US
Practice Address - Phone:512-451-0103
Practice Address - Fax:512-451-2741
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2888207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2194037-02Medicaid
TX2194037-03Medicaid
TX8CW384OtherBCBS INDIVIDUAL #
TXTXB130377Medicare PIN
TXTXB130328Medicare PIN