Provider Demographics
NPI:1053802454
Name:TAM, MARY WING SUM (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WING SUM
Last Name:TAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 NORTH ST STE 415
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:203-628-4995
Practice Address - Street 1:57 NORTH ST STE 415
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5629
Practice Address - Country:US
Practice Address - Phone:203-628-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT6053207W00000X
CT80895207W00000X
FLME163116207W00000X
MA275696207R00000X
NY960492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119673400Medicaid
CT1053802454Medicaid