Provider Demographics
NPI:1528049376
Name:WONG, KAM M (PHD MD)
Entity type:Individual
Prefix:
First Name:KAM
Middle Name:M
Last Name:WONG
Suffix:
Gender:M
Credentials:PHD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 BONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7267
Mailing Address - Country:US
Mailing Address - Phone:419-625-4900
Mailing Address - Fax:419-626-8478
Practice Address - Street 1:1401 BONE CREEK DR
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7267
Practice Address - Country:US
Practice Address - Phone:419-625-4900
Practice Address - Fax:419-626-8478
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3554907207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
W00693921Medicare PIN
E92255Medicare UPIN
OH0829143Medicare ID - Type Unspecified