Basic Information
| Provider Information | |||||||||
| NPI: | 1750398277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445554 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 CONNER RD | ||||||||
| Address2: | |||||||||
| City: | HEBRON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410488142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594426600 | ||||||||
| FaxNumber: | 8594426601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35068687 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 29744 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0171817 | 05 | OH | MEDICAID |