Provider Demographics
NPI:1578563854
Name:WONG, NELSON KIRK (MD)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:KIRK
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 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:618-457-7329
Practice Address - Street 1:13245 KESSLER RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-3101
Practice Address - Country:US
Practice Address - Phone:618-734-4400
Practice Address - Fax:618-734-2884
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106344Medicaid
IL202741Medicare ID - Type Unspecified
IL036106344Medicaid