Provider Demographics
NPI:1376715409
Name:LARRY T. WONG, D.O., P.A.
Entity Type:Organization
Organization Name:LARRY T. WONG, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-215-1080
Mailing Address - Street 1:502 N MACARTHUR AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3654
Mailing Address - Country:US
Mailing Address - Phone:850-215-1080
Mailing Address - Fax:850-215-1086
Practice Address - Street 1:502 N MACARTHUR AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3654
Practice Address - Country:US
Practice Address - Phone:850-215-1080
Practice Address - Fax:850-215-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9154208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
48027YOtherMEDICARE PROVIDER NUMBER
FL270357200Medicaid
48027OtherBLUE CROSS/BLUE SHIELD
FL=========OtherEIN
48027OtherBLUE CROSS/BLUE SHIELD
48027YOtherMEDICARE PROVIDER NUMBER