Provider Demographics
NPI:1841208030
Name:WONG, EDGAR (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
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 1:32-36 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1840
Mailing Address - Country:US
Mailing Address - Phone:570-723-0140
Mailing Address - Fax:570-724-6541
Practice Address - Street 1:32-36 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1840
Practice Address - Country:US
Practice Address - Phone:570-723-0140
Practice Address - Fax:570-724-6541
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030098E207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAWO435288OtherBLUE CROSS/BLUE SHIELD
NY2173426Medicaid
PA0010072670002Medicaid
PAWO435288OtherBLUE CROSS/BLUE SHIELD
NY2173426Medicaid