Provider Demographics
NPI:1982681458
Name:WONG, ALTON (MD)
Entity Type:Individual
Prefix:
First Name:ALTON
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 1:62647 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0626
Mailing Address - Country:US
Mailing Address - Phone:812-962-6407
Mailing Address - Fax:812-471-9282
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4417
Practice Address - Country:US
Practice Address - Phone:773-585-1955
Practice Address - Fax:773-284-5268
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059957207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059957Medicaid
ILD 16169Medicare UPIN
IL036059957Medicaid
IL756960Medicare ID - Type UnspecifiedGROUP 950150