Provider Demographics
NPI:1477610293
Name:WONG, WESLEY BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:BLAKE
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 1:4753 E 136TH ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-9339
Mailing Address - Country:US
Mailing Address - Phone:317-843-9146
Mailing Address - Fax:
Practice Address - Street 1:220 VIRGINIA AVE
Practice Address - Street 2:MAIL NO. IN0205-A547
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3709
Practice Address - Country:US
Practice Address - Phone:317-287-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031410A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25762Medicare UPIN