Provider Demographics
NPI:1629026356
Name:WONG, EDWARD RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RAYMOND
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:20 WALL ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4758
Practice Address - Country:US
Practice Address - Phone:781-221-2800
Practice Address - Fax:781-221-2680
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-05-16
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Provider Licenses
StateLicense IDTaxonomies
MA52950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAV303OtherHARVARD PILGRIM
MA0015268OtherNEIGHBORHOOD HEALTH
MA3014347Medicaid
MA052950OtherTUFTS
MAJ06157OtherBLUE CROSS
MA0015268OtherNEIGHBORHOOD HEALTH
MAJ06157OtherBLUE CROSS