Provider Demographics
NPI:1801939269
Name:CYRIL C WONG LLC
Entity type:Organization
Organization Name:CYRIL C WONG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-688-5700
Mailing Address - Street 1:PO BOX 15430
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-0118
Mailing Address - Country:US
Mailing Address - Phone:352-597-7373
Mailing Address - Fax:352-597-7368
Practice Address - Street 1:11009 HEARTH RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-3723
Practice Address - Country:US
Practice Address - Phone:352-688-5700
Practice Address - Fax:352-688-5548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66960208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003500500Medicaid