Provider Demographics
NPI:1821052242
Name:WONG, JASON H (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:H
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:221 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-3475
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:888-973-8821
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63516207QA0505X
SC86632207QA0505X
NC2021-02364207QA0505X
CODR.0066357207QA0505X
FLTPME5081207QA0505X
AZ63645207QA0505X
TXU1456207QA0505X
WAMD0041655207QA0505X
OH35C.000339207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8361347Medicaid
WA8809131Medicare ID - Type UnspecifiedMEDICARE NUMBER
WAH86598Medicare UPIN