Basic Information
| Provider Information | |||||||||
| NPI: | 1558369124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | BRIGHT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670433 | ||||||||
| FaxNumber: | 4077670608 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073031944 | ||||||||
| FaxNumber: | 4073031746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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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 | 2085N0700X | ME75989 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME75989 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300112441 | 01 | FL | RR MEDICARE | OTHER | 46889 | 01 | FL | BCBS OF FLORIDA | OTHER | 256610900 | 05 | FL | MEDICAID |