Provider Demographics
NPI:1932206315
Name:WONG, ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
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 1:122 W. CHAMPION
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-4429
Mailing Address - Country:US
Mailing Address - Phone:956-287-1207
Mailing Address - Fax:956-287-1292
Practice Address - Street 1:122 W. CHAMPION
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-4429
Practice Address - Country:US
Practice Address - Phone:956-287-1207
Practice Address - Fax:956-287-1292
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1137207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG29742Medicare UPIN
TX8F4556Medicare PIN