Provider Demographics
NPI:1528159332
Name:WONG, EILEEN JAN (MD)
Entity type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:JAN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:180 MORTON ST
Mailing Address - Street 2:4NORTH
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3735
Mailing Address - Country:US
Mailing Address - Phone:617-626-9367
Mailing Address - Fax:617-626-9578
Practice Address - Street 1:180 MORTON ST
Practice Address - Street 2:4NORTH
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-626-9367
Practice Address - Fax:617-626-9578
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA2084P0800X2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE35775Medicare UPIN