Basic Information
| Provider Information | |||||||||
| NPI: | 1962465278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 426 | ||||||||
| Address2: | |||||||||
| City: | OLD WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115680426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165676885 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13626 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113546533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 208297 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VE0102X | 208297 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 02021850 | 05 | NY | MEDICAID |