Basic Information
Provider Information | |||||||||
NPI: | 1730507435 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WONG | ||||||||
FirstName: | WAI CHONG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D.-PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WONG | ||||||||
OtherFirstName: | VIVIAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D.-PH.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 8625 COLLIER BLVD | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341143550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397320044 | ||||||||
FaxNumber: | 2397320094 | ||||||||
Practice Location | |||||||||
Address1: | 8625 COLLIER BLVD | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341143550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397320044 | ||||||||
FaxNumber: | 2397320094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2014 | ||||||||
LastUpdateDate: | 07/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 146288 | FL | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 273799 | 05 | MA |   | MEDICAID |