Provider Demographics
NPI:1336130954
Name:WONG, LISA MEI-INN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MEI-INN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:10 HAWTHORNE PL
Practice Address - Street 2:SUITE 110
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2336
Practice Address - Country:US
Practice Address - Phone:617-724-0924
Practice Address - Fax:617-724-3413
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA55558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05372OtherBCBS MA
MA719240OtherTUFTS HEALTH PLAN
MA3004538Medicaid
E01864Medicare UPIN
MA3004538Medicaid