Provider Demographics
NPI:1023692753
Name:WONG, DANIEL JONATHAN (DPM)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JONATHAN
Last Name:WONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22712 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:718-869-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007406213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program