Provider Demographics
NPI:1972683159
Name:WONG, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
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 1:901 BOREN AVE
Mailing Address - Street 2:SUITE 711
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3595
Mailing Address - Country:US
Mailing Address - Phone:206-622-6987
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE
Practice Address - Street 2:SUITE 711
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3595
Practice Address - Country:US
Practice Address - Phone:206-622-6987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1507409Medicaid
WA1507409Medicaid