Provider Demographics
NPI:1154946424
Name:WONG, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 PHYSICIANS DRIVE SUITE A
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650
Mailing Address - Country:US
Mailing Address - Phone:864-797-9150
Mailing Address - Fax:864-797-9155
Practice Address - Street 1:250 HARRISON ST FL 2ND
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5094
Practice Address - Country:US
Practice Address - Phone:321-268-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL84609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine