Basic Information
| Provider Information | |||||||||
| NPI: | 1104889591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 GOLDEN RIDGE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804019541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032331223 | ||||||||
| FaxNumber: | 3032338755 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 GOLDEN RIDGE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804019541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032331223 | ||||||||
| FaxNumber: | 3032338755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35887 | CO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 35887 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 01358878 | 05 | CO | MEDICAID |