Provider Demographics
NPI:1821013343
Name:WONG, MARILYN (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10507
Mailing Address - Country:US
Mailing Address - Phone:914-666-2220
Mailing Address - Fax:914-666-2987
Practice Address - Street 1:52 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD HILLS
Practice Address - State:NY
Practice Address - Zip Code:10507
Practice Address - Country:US
Practice Address - Phone:914-666-2220
Practice Address - Fax:914-666-2987
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21343112085R0202X
NY2134312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2105411Medicaid
NY02105411Medicaid
NY02105411Medicaid
NY974671Medicare PIN