Provider Demographics
NPI:1760580260
Name:WONG, KARL (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0447
Mailing Address - Country:US
Mailing Address - Phone:814-375-3286
Mailing Address - Fax:814-375-3384
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-375-3286
Practice Address - Fax:814-375-3384
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-037091Y207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009646330004Medicaid
PA000013308OtherBLUE CROSS/BLUE SHIELD
PA0009646330004Medicaid