Provider Demographics
NPI:1881689511
Name:WONG, SERENA T (MD)
Entity type:Individual
Prefix:DR
First Name:SERENA
Middle Name:T
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 LITTLE ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1914
Mailing Address - Country:US
Mailing Address - Phone:908-295-2172
Mailing Address - Fax:
Practice Address - Street 1:195 LITTLE ALBANY ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1914
Practice Address - Country:US
Practice Address - Phone:908-295-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07741300207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0048526Medicaid
NJ085901P3VMedicare PIN
NJ0048526Medicaid
NJ085901S6SMedicare PIN
NJ085901AHEMedicare PIN
NJ085901Medicare ID - Type Unspecified