Provider Demographics
NPI:1063401248
Name:WONG, CHARLES W (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:310 S MAIN ST
Mailing Address - Street 2:PO BOX 148
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-1129
Mailing Address - Country:US
Mailing Address - Phone:270-298-9136
Mailing Address - Fax:270-298-9039
Practice Address - Street 1:310 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1129
Practice Address - Country:US
Practice Address - Phone:270-298-9136
Practice Address - Fax:270-298-9039
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY2041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1D65909921Medicaid
C69393Medicare UPIN
KY1D65909921Medicaid