Provider Demographics
NPI:1013982610
Name:WONG, HUMPHREY (MD)
Entity type:Individual
Prefix:DR
First Name:HUMPHREY
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 1:1801 E 54TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7214
Mailing Address - Country:US
Mailing Address - Phone:563-323-1229
Mailing Address - Fax:563-323-8240
Practice Address - Street 1:1801 E 54TH ST
Practice Address - Street 2:STE 100
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7209
Practice Address - Country:US
Practice Address - Phone:563-323-1229
Practice Address - Fax:563-323-8240
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093604207RP1001X
IA31235207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0138024Medicaid
IA290008119OtherRAILROAD MEDICARE
IL290010030OtherRAILROAD MEDICARE
ILL62239Medicare ID - Type Unspecified
IA0138024Medicaid
IA54460Medicare ID - Type Unspecified