Provider Demographics
NPI:1346262128
Name:WONG, JOAQUIN (MD)
Entity Type:Individual
Prefix:
First Name:JOAQUIN
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 1:200 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118
Mailing Address - Country:US
Mailing Address - Phone:504-896-9458
Mailing Address - Fax:504-894-5140
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-896-9458
Practice Address - Fax:504-894-5140
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11463R208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118507Medicaid
LA1664472Medicaid
LA1664472Medicaid
G08548Medicare UPIN
MS00118507Medicaid
LA5W315F669Medicare PIN