Provider Demographics
NPI:1952337818
Name:WONG, KONG WAI (DO)
Entity Type:Individual
Prefix:DR
First Name:KONG
Middle Name:WAI
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:28482 CHERRY HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-4703
Mailing Address - Country:US
Mailing Address - Phone:734-425-2828
Mailing Address - Fax:734-425-1138
Practice Address - Street 1:28482 CHERRY HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4703
Practice Address - Country:US
Practice Address - Phone:734-425-2828
Practice Address - Fax:734-425-1138
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2126155Medicaid
MI2126155Medicaid
MIF05095Medicare ID - Type Unspecified