Provider Demographics
NPI:1992824866
Name:WONG, ROSALIE L (MD)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:L
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5225 NESCONSET HWY
Mailing Address - Street 2:SUITE 36
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2053
Mailing Address - Country:US
Mailing Address - Phone:631-928-4870
Mailing Address - Fax:631-928-4910
Practice Address - Street 1:5225 NESCONSET HWY
Practice Address - Street 2:SUITE 36
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-928-4870
Practice Address - Fax:631-928-4910
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1116472080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB77894Medicare UPIN