Provider Demographics
NPI:1841291929
Name:WONG, BRYAN Y (MD PHD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:Y
Last Name:WONG
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 E BANNER GATEWAY DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2168
Mailing Address - Country:US
Mailing Address - Phone:480-265-6444
Mailing Address - Fax:480-265-4607
Practice Address - Street 1:2946 E BANNER GATEWAY DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-4607
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11456207RH0003X
AZ41477207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00732871OtherRAILROAD MEDICARE
AZ406300Medicaid
NV101038Medicare PIN
AZP00732871OtherRAILROAD MEDICARE
NVI34361Medicare UPIN
AZZ127664Medicare PIN