Provider Demographics
NPI:1679912539
Name:WONG, MICHELLE V (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:V
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD STE 180
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5255
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:208 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:508-973-2661
Practice Address - Fax:508-973-0314
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA268676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine