Provider Demographics
NPI:1497700975
Name:WONGSUWAN, SUWONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SUWONG
Middle Name:
Last Name:WONGSUWAN
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 32
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0032
Mailing Address - Country:US
Mailing Address - Phone:509-897-2600
Mailing Address - Fax:509-897-5747
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:ST MARY MEDICAL CENTER, CARDIOLOGY SUITE
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-897-2600
Practice Address - Fax:509-897-5747
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD39949207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806100200Medicaid
WA1011703Medicaid
OR288534Medicaid
WA1011703Medicaid
OR288534Medicaid