Provider Demographics
NPI:1437177193
Name:WONG, KEVIN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2057 ROUTE 130
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-3801
Mailing Address - Country:US
Mailing Address - Phone:724-527-2700
Mailing Address - Fax:724-527-2705
Practice Address - Street 1:2057 ROUTE 130
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-3801
Practice Address - Country:US
Practice Address - Phone:724-527-2700
Practice Address - Fax:724-527-2705
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038763L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008535900001Medicaid
PA009870U31Medicare PIN
PAP00668600Medicare PIN
PAC26371Medicare UPIN