Provider Demographics
NPI:1982786844
Name:WONGANANDA, T. JOE
Entity Type:Individual
Prefix:DR
First Name:T.
Middle Name:JOE
Last Name:WONGANANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 LANDMARK DR
Mailing Address - Street 2:SUITE 128 - 129
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4966
Mailing Address - Country:US
Mailing Address - Phone:443-926-9147
Mailing Address - Fax:443-926-9151
Practice Address - Street 1:806 LANDMARK DR
Practice Address - Street 2:SUITE 128 - 129
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4966
Practice Address - Country:US
Practice Address - Phone:443-926-9147
Practice Address - Fax:443-926-9151
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01281213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU83974Medicare UPIN