Provider Demographics
NPI:1508810136
Name:WONG, WENDY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LYNN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1619
Mailing Address - Country:US
Mailing Address - Phone:214-826-8822
Mailing Address - Fax:214-826-9792
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-826-8822
Practice Address - Fax:214-826-9792
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM03152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171824903Medicaid
TX171824901Medicaid
TX171824902Medicaid
TX171824904Medicaid
TX171824902Medicaid
TX8D3709Medicare PIN
TX8F3941Medicare PIN
TX171824904Medicaid
TX171824903Medicaid
TX8D9097Medicare PIN