Provider Demographics
NPI:1922171925
Name:WONG, MAICIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MAICIE
Middle Name:M
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 E 79TH ST
Mailing Address - Street 2:SUITE 23
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0150
Mailing Address - Country:US
Mailing Address - Phone:212-355-8100
Mailing Address - Fax:
Practice Address - Street 1:16 E 79TH ST
Practice Address - Street 2:SUITE 23
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0150
Practice Address - Country:US
Practice Address - Phone:212-355-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2142691208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02183599Medicaid
H37099Medicare UPIN