Provider Demographics
NPI:1245475581
Name:WONG, DAVID TOM (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TOM
Last Name:WONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-518-5814
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-518-5814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006302213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03399731Medicaid
NY03399731Medicaid