Provider Demographics
NPI:1174977904
Name:DONG, JIAN WILSON
Entity type:Individual
Prefix:
First Name:JIAN
Middle Name:WILSON
Last Name:DONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-6757
Mailing Address - Fax:
Practice Address - Street 1:15 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1099
Practice Address - Country:US
Practice Address - Phone:207-363-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH229472085N0904X
MEMD243252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology