Provider Demographics
NPI:1851613194
Name:WONG, JIM (MD)
Entity Type:Individual
Prefix:
First Name:JIM
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 1:2001 CRYSTAL SPRING AVE SW STE 301
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2465
Mailing Address - Country:US
Mailing Address - Phone:540-981-7715
Mailing Address - Fax:540-981-7965
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 301
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-981-7715
Practice Address - Fax:540-981-7965
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253634207R00000X, 207R00000X
NH16249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine