Provider Demographics
NPI:1962465278
Name:WONG, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
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:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-0426
Mailing Address - Country:US
Mailing Address - Phone:516-567-6885
Mailing Address - Fax:
Practice Address - Street 1:13626 37TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6533
Practice Address - Country:US
Practice Address - Phone:718-886-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208297207V00000X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02021850Medicaid
H10629Medicare UPIN
NY0105MWMedicare PIN