Provider Demographics
NPI:1083438089
Name:WONG SAM, FERNANDO (MDOM)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:WONG SAM
Suffix:
Gender:M
Credentials:MDOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 E LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5401
Mailing Address - Country:US
Mailing Address - Phone:352-222-5806
Mailing Address - Fax:
Practice Address - Street 1:1215 E LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5401
Practice Address - Country:US
Practice Address - Phone:407-885-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4576171100000X
FL106005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist