Provider Demographics
NPI:1780886549
Name:T JOE WONGANANDA DPM PA
Entity type:Organization
Organization Name:T JOE WONGANANDA DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAAN
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:WONGANANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:443-926-9147
Mailing Address - Street 1:806 LANDMARK DR
Mailing Address - Street 2:STE 128 - 129
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4966
Mailing Address - Country:US
Mailing Address - Phone:443-926-9147
Mailing Address - Fax:443-926-9151
Practice Address - Street 1:806 LANDMARK DR
Practice Address - Street 2:STE 128 - 129
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4966
Practice Address - Country:US
Practice Address - Phone:443-926-9147
Practice Address - Fax:443-926-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01281213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1982786844OtherMY INDIVIDUAL NPI
MD166603700Medicaid
MD1982786844OtherMY INDIVIDUAL NPI
MDU83974Medicare UPIN