Provider Demographics
NPI:1639318132
Name:WONGSAM, PATRICIA E (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:WONGSAM
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:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-0529
Mailing Address - Country:US
Mailing Address - Phone:614-581-2115
Mailing Address - Fax:614-261-1700
Practice Address - Street 1:1747 BRYDEN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2221
Practice Address - Country:US
Practice Address - Phone:614-581-2115
Practice Address - Fax:614-261-1700
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043185208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHD31174Medicare UPIN