Provider Demographics
NPI:1679504344
Name:WONGCHANTARA, DANITA ROBERTA (MD)
Entity Type:Individual
Prefix:DR
First Name:DANITA
Middle Name:ROBERTA
Last Name:WONGCHANTARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:DANITA
Other - Middle Name:ROBERTA
Other - Last Name:TANGSINMANKONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:461 7TH AVE S
Mailing Address - Street 2:D R WONG, MED-PED, P.A.
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4818
Mailing Address - Country:US
Mailing Address - Phone:727-823-1111
Mailing Address - Fax:727-823-4153
Practice Address - Street 1:461 7TH AVE S
Practice Address - Street 2:D R WONG, MED-PED, P.A.
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4818
Practice Address - Country:US
Practice Address - Phone:727-823-1111
Practice Address - Fax:727-823-4153
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0076151207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5501747OtherAETNA NON-HMO
FL2590539OtherAETNA HMO
FL44234OtherBCBS
FLH00206Medicare UPIN
FL44234 ZMedicare ID - Type Unspecified