Provider Demographics
NPI:1477628584
Name:WONG, RUSSELL HOW KEONG (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:HOW KEONG
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:PO BOX 741087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1087
Mailing Address - Country:US
Mailing Address - Phone:727-588-5812
Mailing Address - Fax:727-588-5911
Practice Address - Street 1:201 14TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3133
Practice Address - Country:US
Practice Address - Phone:727-588-5812
Practice Address - Fax:727-588-5911
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87050207ZP0102X, 207ZC0500X, 207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F37054Medicare UPIN