Provider Demographics
NPI:1821362344
Name:WONG, IRENE (DO)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:HOLIAM
Other - Middle Name:IRENE
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:650 UNION BLVD UNIT 16
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512
Practice Address - Country:US
Practice Address - Phone:973-938-5200
Practice Address - Fax:973-938-5191
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260111207Q00000X
NJ25MB10295000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03480408Medicaid