Provider Demographics
NPI:1538265236
Name:WONG, JAN HOWE (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:HOWE
Last Name:WONG
Suffix:
Gender:M
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:P.O. BOX 751069
Mailing Address - Street 2:ECU PHYSICAINS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS AT LEO W. JENKINS CANCER SERVICES
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-1888
Practice Address - Fax:252-744-7005
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-015822086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00533401Medicaid
NC5915789Medicaid
NC1590COtherBCBSNC
HIH0000BDVTFMedicare ID - Type Unspecified
HI00533401Medicaid
NC5915789Medicaid
NC2076653Medicare PIN