Basic Information
| Provider Information | |||||||||
| NPI: | 1861846909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JOHNSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S NEW BALLAS RD STE 112A | ||||||||
| Address2: | |||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
| FaxNumber: | 3142514564 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD STE 112A | ||||||||
| Address2: | |||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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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 | 207R00000X | 2019012319 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.