Provider Demographics
NPI:1952462079
Name:WONG, PHILLIP ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ALLEN
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:PHILLIP
Other - Middle Name:ALLEN
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:10211 MONTGOMERY BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3608
Mailing Address - Country:US
Mailing Address - Phone:505-296-8968
Mailing Address - Fax:
Practice Address - Street 1:10211 MONTGOMERY BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3608
Practice Address - Country:US
Practice Address - Phone:505-296-8968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-823-85204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC96758Medicare UPIN