Provider Demographics
NPI:1780783498
Name:WONG, CHARISSA J (MD)
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:J
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 1:571 CENTRAL AVE SUITE 101
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974
Mailing Address - Country:US
Mailing Address - Phone:908-464-4600
Mailing Address - Fax:908-464-4737
Practice Address - Street 1:571 CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1547
Practice Address - Country:US
Practice Address - Phone:908-464-4600
Practice Address - Fax:908-464-4737
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA8601700207W00000X
NJ25MA08601700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00B519P91Medicare ID - Type Unspecified
H51384Medicare UPIN