Provider Demographics
NPI:1437179199
Name:WONG, ERIC T (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:SHAPIRO EIGHTH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-1665
Mailing Address - Fax:617-667-1664
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:SHAPIRO EIGHTH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-1665
Practice Address - Fax:617-667-1664
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1537652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3167411Medicaid
MAE82091Medicare UPIN
MAA22609Medicare ID - Type Unspecified