Basic Information
| Provider Information | |||||||||
| NPI: | 1700087400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 14000 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852102008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805458119 | ||||||||
| FaxNumber: | 4805450102 | ||||||||
| Practice Location | |||||||||
| Address1: | 6424 E BROADWAY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804569000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301079902 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 41722 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 41722 | 01 | AZ | AZ MEDICAL BOARD STATE LICENSE | OTHER | 424901 | 05 | AZ | MEDICAID |