Provider Demographics
NPI:1821054081
Name:WONG, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
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 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-521-5800
Mailing Address - Fax:602-521-5334
Practice Address - Street 1:1441 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-521-5800
Practice Address - Fax:602-521-5334
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ870304Medicaid
Z123504Medicare PIN
AZZ106231Medicare PIN
AZZ143783Medicare PIN
I11175Medicare UPIN
AZZ143788Medicare PIN
AZZ144537Medicare PIN
AZZ106234Medicare PIN
AZZ144538Medicare UPIN
AZ870304Medicaid
AZZ79779Medicare PIN