Provider Demographics
NPI:1174785190
Name:FOO, WAI LEONG (DO)
Entity type:Individual
Prefix:DR
First Name:WAI LEONG
Middle Name:
Last Name:FOO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:BENJAMIN WAI-LEONG
Other - Middle Name:
Other - Last Name:FOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:201 DEFENSE HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7096
Mailing Address - Country:US
Mailing Address - Phone:410-571-2946
Mailing Address - Fax:
Practice Address - Street 1:116 DEFENSE HWY STE 403
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7020
Practice Address - Country:US
Practice Address - Phone:410-571-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0077189208100000X
TNDO2293208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A11252OtherOSTEOPATHIC MEDICAL BOARD LICENSE
TN1524902Medicaid
TN1524902Medicaid
TN1524902Medicaid
CADH984ZMedicare PIN
CADH984YMedicare PIN