Provider Demographics
NPI:1659362820
Name:WONG, JOHNSON TAI (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:TAI
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 1:8 HAWTHORNE PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2335
Mailing Address - Country:US
Mailing Address - Phone:617-742-5730
Mailing Address - Fax:617-742-6917
Practice Address - Street 1:8 HAWTHORNE PL
Practice Address - Street 2:SUITE 104
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2335
Practice Address - Country:US
Practice Address - Phone:617-742-5730
Practice Address - Fax:617-742-6917
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53165207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05499OtherBCBS MA
MA3009017Medicaid
MA713318OtherTUFTS HEALTH PLAN
MA713318OtherTUFTS HEALTH PLAN
MA3009017Medicaid