Provider Demographics
NPI:1669486437
Name:WONG, SO CHING (DPM)
Entity Type:Individual
Prefix:
First Name:SO
Middle Name:CHING
Last Name:WONG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1113 S MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3436
Mailing Address - Country:US
Mailing Address - Phone:203-271-2552
Mailing Address - Fax:203-271-3301
Practice Address - Street 1:1113 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3436
Practice Address - Country:US
Practice Address - Phone:203-271-2552
Practice Address - Fax:203-271-3301
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000541213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004113411Medicaid
480000693OtherMEDICARE
CT004113411Medicaid
U18536Medicare UPIN