Provider Demographics
NPI:1427005784
Name:WONG, PERRY (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
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 1:10450 NEWHAVEN ROAD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030
Mailing Address - Country:US
Mailing Address - Phone:513-981-5852
Mailing Address - Fax:513-367-8031
Practice Address - Street 1:10450 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-2780
Practice Address - Country:US
Practice Address - Phone:513-981-5852
Practice Address - Fax:513-367-8031
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0625612Medicaid
OH0625612Medicaid
OH4238602Medicare PIN