Provider Demographics
NPI:1891115945
Name:WONG, BRIAN KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KENNETH
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 1:4417 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2319
Mailing Address - Country:US
Mailing Address - Phone:215-302-3600
Mailing Address - Fax:901-260-8590
Practice Address - Street 1:969 FRAYSER BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-5977
Practice Address - Country:US
Practice Address - Phone:901-842-3162
Practice Address - Fax:901-842-2362
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2023-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD481351208000000X, 207R00000X
TN56026208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty