Provider Demographics
NPI:1801890314
Name:WONG, CHARLES CHU-LI (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CHU-LI
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1729 KINNEYS LANE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3167
Mailing Address - Country:US
Mailing Address - Phone:740-354-2942
Mailing Address - Fax:704-353-3661
Practice Address - Street 1:1729 KINNEYS LANE
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3167
Practice Address - Country:US
Practice Address - Phone:740-354-2942
Practice Address - Fax:740-353-3661
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH63264207RG0100X
OH35063264W207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0879705Medicaid
OHW00717905Medicare PIN
OH0879705Medicaid