Provider Demographics
NPI:1942286760
Name:WONG, KATY K (MD)
Entity Type:Individual
Prefix:DR
First Name:KATY
Middle Name:K
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 1:611 W. PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3552
Practice Address - Country:US
Practice Address - Phone:309-663-8311
Practice Address - Fax:309-661-3390
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110197207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5715384OtherBLUE CROSS BLUE SHIELD
IL036110197Medicaid
IL036110197Medicaid
545260Medicare ID - Type Unspecified
ILK03908Medicare PIN