Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | 0447000045 | VA |
N | 1223G0001X | General Practice | 0401414467 | VA |
N | 213EG0000X | General Practice | 0401414467 | VA |
NPI | 1225266430 |
---|---|
Provider Name | Dr. Jonathan L Wong |
First Address | Norfolk, VA 23502-3950 |
Second Address | Norfolk, VA 23502-3950 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2009 |
Last Update Date | 14/07/2020 |