Provider Demographics
NPI:1134214307
Name:WONG, JASON T (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE ST SE MMC 292
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-273-6004
Mailing Address - Fax:612-273-8459
Practice Address - Street 1:500 HARVARD STREET SE
Practice Address - Street 2:UNIT J2-300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-273-6004
Practice Address - Fax:612-273-8459
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN478262085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0144508Medicaid
IA0594143Medicaid
MN2366354OtherAMERICA'S PPO
MN615T6WOOtherBCBS MN
MN208670100Medicaid
MN132919OtherUCARE
MNB632OtherCHAMPUS
WI34666400Medicaid
MN238881OtherFAIRVIEW
MNHP52811OtherHEALTHPARTNERS
MN16-02032OtherMEDICA PRIMARY
MN16-03682OtherMEDICA - CHOICE
MN1044141OtherPREFERREDONE
MN16-02032OtherMEDICA PRIMARY
MN940000086Medicare ID - Type Unspecified