Provider Demographics
NPI:1427071521
Name:WONG, PETER L (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:L
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:PO BOX 27829
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125
Mailing Address - Country:US
Mailing Address - Phone:505-232-1920
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:9109 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-275-4288
Practice Address - Fax:505-275-4203
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF0052Medicaid
G88671Medicare UPIN