Provider Demographics
NPI:1629496591
Name:MELVIN C. W. WONG M, D, INC.
Entity Type:Organization
Organization Name:MELVIN C. W. WONG M, D, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:C W
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:808-487-4960
Mailing Address - Street 1:98-1247 KAAHUMANU ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5311
Mailing Address - Country:US
Mailing Address - Phone:808-487-7960
Mailing Address - Fax:808-488-6737
Practice Address - Street 1:98-1247 KAAHUMANU ST
Practice Address - Street 2:SUITE 318
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5311
Practice Address - Country:US
Practice Address - Phone:808-487-7960
Practice Address - Fax:808-488-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 6869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH100940Medicaid
HIE54519Medicare UPIN
HIH100940Medicaid