Basic Information
| Provider Information | |||||||||
| NPI: | 1174977904 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONG | ||||||||
| FirstName: | JIAN | ||||||||
| MiddleName: | WILSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177326757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 HOSPITAL DR | ||||||||
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| City: | YORK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039091099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073634321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2016 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD24325 | ME | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.