Basic Information
| Provider Information | |||||||||
| NPI: | 1811916745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1511 PARK AVE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070805516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085619500 | ||||||||
| FaxNumber: | 9085617162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 PARK AVE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070805516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085619500 | ||||||||
| FaxNumber: | 9085617162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 25MA08099600 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 25MA08099600 | NJ | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 6485178 | 01 | NJ | CIGNA | OTHER | 2675738 | 01 | NJ | UNITED HEALTHCARE | OTHER | 7731734 | 01 | AETNA | OTHER | P3701421 | 01 | NJ | OXFORD | OTHER |