Provider Demographics
NPI:1053338590
Name:WONG, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WONG
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6120
Mailing Address - Fax:314-454-4225
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV NEUROLOGY PEDIATRICS, STE 2130
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6120
Practice Address - Fax:314-454-4225
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111200208000000X, 2084N0402X, 2084N0600X, 2084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205453202Medicaid
MO370018891Medicare PIN
MO141010101Medicaid
IL$$$$$$$$$Medicaid