Provider Demographics
NPI:1154361301
Name:KWONG, MICHAEL DIEM (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DIEM
Last Name:KWONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC8095OtherMEDCOST
NCC9018OtherMEDCOST
NCP00108512OtherRAILROAD MEDICARE
NC7977500OtherAETNA
NC89134RVMedicaid
NC134RVOtherBLUECROSS BLUESHIELD
NC16-01420OtherUNITED HEALTHCARE
NCP00044401OtherRAILROAD MEDICARE
NCP00263421OtherRAILROAD MEDICARE
NCC9019OtherMEDCOST
NC16-01415OtherUNITED HEALTHCARE
NC16-01419OtherUNITED HEALTHCARE
NC134RVOtherBLUECROSS BLUESHIELD
NC16-01419OtherUNITED HEALTHCARE
NCP00044401OtherRAILROAD MEDICARE
NCC9019OtherMEDCOST