Provider Demographics
NPI:1053593848
Name:WONG, STEVEN S
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:S
Last Name:WONG
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 1:14 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1524
Mailing Address - Country:US
Mailing Address - Phone:516-482-1021
Mailing Address - Fax:
Practice Address - Street 1:35 W 125TH ST # 45
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4511
Practice Address - Country:US
Practice Address - Phone:212-828-1772
Practice Address - Fax:212-987-9283
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01917000Medicaid