Provider Demographics
NPI:1558479402
Name:WONG, JEFFREY G (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:G
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 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:303 BENNER PIKE STE 1
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7304
Practice Address - Country:US
Practice Address - Phone:814-272-5660
Practice Address - Fax:814-272-5675
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAL27458207R00000X
PAMD455716207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030496070001Medicaid
SCQ32070Medicaid
PA1030496070001Medicaid