Provider Demographics
NPI:1811051311
Name:WONG, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2705
Mailing Address - Country:US
Mailing Address - Phone:617-629-6280
Mailing Address - Fax:617-629-6275
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6280
Practice Address - Fax:617-629-6275
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA52853207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA796024OtherTUFTS
MA001432OtherNHP
MA0014532OtherBCBS
MA9398696-002OtherCIGNA
MA3193560Medicaid
MAE143OtherHPHC
MAJ03334OtherBCBS
MAE143OtherHPHC
MAB74443Medicare UPIN