Provider Demographics
NPI:1780685990
Name:WONG, KENNETH MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MATTHEW
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 1:3433 N.W. 56TH STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-947-3341
Mailing Address - Fax:
Practice Address - Street 1:3433 NW 56TH ST
Practice Address - Street 2:STE 400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4430
Practice Address - Country:US
Practice Address - Phone:405-947-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18891207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease