Provider Demographics
NPI:1720233984
Name:WONG, SAMSON (LMT)
Entity Type:Individual
Prefix:MR
First Name:SAMSON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8924 OLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1916
Mailing Address - Country:US
Mailing Address - Phone:847-275-5990
Mailing Address - Fax:
Practice Address - Street 1:2522 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2352
Practice Address - Country:US
Practice Address - Phone:773-296-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227000055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist