Provider Demographics
NPI:1801070511
Name:BERT YS WONG, MD, LLC
Entity type:Organization
Organization Name:BERT YS WONG, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:YS
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-636-9225
Mailing Address - Street 1:40 BERTHE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3162
Mailing Address - Country:US
Mailing Address - Phone:719-636-9225
Mailing Address - Fax:719-636-9377
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 700
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-635-7172
Practice Address - Fax:719-636-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25298207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC506768Medicare PIN
COD24605Medicare UPIN