Provider Demographics
NPI:1659394187
Name:WONG, CHARLES MEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MEN
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4160 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5336
Mailing Address - Country:US
Mailing Address - Phone:503-249-9000
Mailing Address - Fax:503-719-6823
Practice Address - Street 1:2850 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:503-666-7410
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD14849208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC91134Medicare UPIN