Provider Demographics
NPI:1952494064
Name:WONG, TAI KEONG (MD)
Entity type:Individual
Prefix:
First Name:TAI
Middle Name:KEONG
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12907 TANTARA DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-6450
Mailing Address - Country:US
Mailing Address - Phone:512-335-3421
Mailing Address - Fax:512-335-3421
Practice Address - Street 1:2203 W 35TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-1203
Practice Address - Country:US
Practice Address - Phone:512-374-6950
Practice Address - Fax:512-374-6080
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0037AMOtherBCBS PROVIDER NUMBER