Provider Demographics
NPI:1346474202
Name:WONG, JENNIFER LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
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:PO BOX 208063
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8063
Mailing Address - Country:US
Mailing Address - Phone:203-785-3091
Mailing Address - Fax:203-785-6885
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-3091
Practice Address - Fax:203-785-6885
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254271207VM0101X, 207VM0101X
CT54528207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03460964Medicaid
NYA400069231Medicare PIN