Provider Demographics
NPI:1316941792
Name:WONG, JEANNE (MD)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
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:PO BOX 827944
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7944
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:300 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2819
Practice Address - Country:US
Practice Address - Phone:973-672-8400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03869100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3939201Medicaid
E53468Medicare UPIN
NJ505868Medicare ID - Type Unspecified