Provider Demographics
NPI:1396715652
Name:WONG, DOMINIQUE M (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:M
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3804
Mailing Address - Country:US
Mailing Address - Phone:304-526-2200
Mailing Address - Fax:304-399-1507
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-526-2200
Practice Address - Fax:304-399-1507
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19271207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100102840Medicaid
OH2972832Medicaid
WV1396715652Medicaid