Provider Demographics
NPI:1851397988
Name:WONG, RANDALL VERNON (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:VERNON
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3400 BEE RIDGE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-7243
Mailing Address - Country:US
Mailing Address - Phone:703-876-9630
Mailing Address - Fax:703-876-0163
Practice Address - Street 1:3025 HAMAKER CT
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2237
Practice Address - Country:US
Practice Address - Phone:703-876-9630
Practice Address - Fax:703-876-0163
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2016-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0041207174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD497691600Medicaid
MD541S541SMedicare PIN
MDF29890Medicare UPIN