Basic Information
| Provider Information | |||||||||
| NPI: | 1649477167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG-LOPEZ | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WONG-DOMINGUEZ | ||||||||
| OtherFirstName: | JAIME | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9300 DEWITT LOOP | ||||||||
| Address2: | FORT BELVOIR COMMUNITY HOSPITAL, FAMILY MEDICINE CLINIC | ||||||||
| City: | FORT BELVOIR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220605285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9300 DEWITT LOOP | ||||||||
| Address2: | FORT BELVOIR COMMUNITY HOSPITAL, FAMILY MEDICINE CLINIC | ||||||||
| City: | FORT BELVOIR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220605285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712311994 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 06/15/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0101246156 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 0101246156 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.