Provider Demographics
NPI:1457424392
Name:WONG, EDISON (MD)
Entity Type:Individual
Prefix:
First Name:EDISON
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 1:668 N ORLANDO AVE STE 1010
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4460
Mailing Address - Country:US
Mailing Address - Phone:407-644-0101
Mailing Address - Fax:321-441-1559
Practice Address - Street 1:668 N ORLANDO AVE STE 1010
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4460
Practice Address - Country:US
Practice Address - Phone:407-644-0101
Practice Address - Fax:321-441-1559
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0407512081P2900X
MA812932081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ31343OtherBCBS
MA30555OtherFALLON
MA80911OtherHARV PILGRIM
MA758575OtherTUFTS
MA972848OtherNETWORK HEALTH
MA3139875Medicaid
MAP00132480OtherMR RR
MA3139875Medicaid
MA3139875Medicaid