Provider Demographics
NPI:1639302169
Name:WONG, CRISTY A (MD)
Entity Type:Individual
Prefix:
First Name:CRISTY
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRISTY
Other - Middle Name:ANNET
Other - Last Name:LEON HIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:521 WEST STATE ROAD 434, SUITE 101 PEDIATRIC
Practice Address - Street 2:& ADOLESCENT MED OF SEMINOLE, IIN ASSOC WITH NEMOURS
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4952
Practice Address - Country:US
Practice Address - Phone:407-830-5437
Practice Address - Fax:407-830-4907
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105408208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL'001444100Medicaid