Provider Demographics
NPI:1538228390
Name:WONG, LEI (MD)
Entity type:Individual
Prefix:DR
First Name:LEI
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 1:16 E JOHN ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-1310
Mailing Address - Country:US
Mailing Address - Phone:516-938-3388
Mailing Address - Fax:516-938-3389
Practice Address - Street 1:16 E JOHN ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1310
Practice Address - Country:US
Practice Address - Phone:516-938-3388
Practice Address - Fax:516-938-3389
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01624175Medicaid
NY18N141Medicare ID - Type Unspecified
NY01624175Medicaid