Provider Demographics
NPI:1639581093
Name:MARTHA SHIH WONG MD
Entity Type:Organization
Organization Name:MARTHA SHIH WONG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:SHIH
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-969-2783
Mailing Address - Street 1:127 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-2003
Mailing Address - Country:US
Mailing Address - Phone:917-969-2783
Mailing Address - Fax:718-665-5335
Practice Address - Street 1:860 GRAND CONCOURSE
Practice Address - Street 2:SUITE 1C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-2814
Practice Address - Country:US
Practice Address - Phone:718-665-7384
Practice Address - Fax:718-665-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113881173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00208131Medicaid
113881OtherNYS LICENSE