Provider Demographics
NPI:1760440531
Name:WONG, KIN S (DO)
Entity Type:Individual
Prefix:
First Name:KIN
Middle Name:S
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 1:2327 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-2904
Mailing Address - Country:US
Mailing Address - Phone:817-834-1655
Mailing Address - Fax:817-834-1659
Practice Address - Street 1:2327 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-2904
Practice Address - Country:US
Practice Address - Phone:817-834-1655
Practice Address - Fax:817-834-1659
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9458207P00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149752104Medicaid
TX149752106Medicaid
TX149752111Medicaid
TX0063LSOtherBCBS
TXP00193257Medicare PIN
TXH56846Medicare UPIN
TX611121Medicare PIN
TX0063LSOtherBCBS
TX8B5869Medicare PIN