Provider Demographics
NPI:1669440814
Name:WONG, CARSON (MD)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
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 1:6900 PEARL RD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3639
Mailing Address - Country:US
Mailing Address - Phone:440-845-0900
Mailing Address - Fax:440-842-9911
Practice Address - Street 1:400 MATTHEW ST STE 303
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-373-7828
Practice Address - Fax:740-373-5898
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-12
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23694208800000X
OH35052657208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3154616Medicaid
OH3154616Medicaid