Provider Demographics
NPI:1396721742
Name:WONG, ROLAND W (MD)
Entity type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:W
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 1:6600 VAN AALST BLVD BLDG 9250
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-2078
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-2078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0523832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA971246837Medicaid
AL140301Medicaid
GA202I308179Medicare PIN
GA30BDLHSMedicare ID - Type Unspecified