Provider Demographics
NPI:1669826285
Name:WONG, KENNETH RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RICHARD
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 1:525 EAST 68TH STREET, MAILBOX 301
Mailing Address - Street 2:NY PRESBYTERIAN CORNELL- EMERGENCY MEDICINE RESIDENCY
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:949-903-0215
Mailing Address - Fax:
Practice Address - Street 1:525 EAST 68TH STREET, MAILBOX 301
Practice Address - Street 2:NY PRESBYTERIAN CORNELL- EMERGENCY MEDICINE RESIDENCY
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:949-903-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084070A207P00000X
CT910442318390200000X
KS04-45699207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD7686569OtherCALIFORNIA DRIVER'S LICENSE