Provider Demographics
NPI:1689641599
Name:WONG, LARRY T (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 N MACARTHUR AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3636
Mailing Address - Country:US
Mailing Address - Phone:850-215-1080
Mailing Address - Fax:850-215-1086
Practice Address - Street 1:502 N MACARTHUR AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3636
Practice Address - Country:US
Practice Address - Phone:850-215-1080
Practice Address - Fax:850-215-1086
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9154208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48027OtherBLUE CROSS
FL48027OtherBLUE CROSS
FLI20327Medicare UPIN