Provider Demographics
NPI:1730175340
Name:WONG, GRAND FU KWOK (MD)
Entity type:Individual
Prefix:
First Name:GRAND
Middle Name:FU KWOK
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-844-4300
Mailing Address - Fax:405-844-4333
Practice Address - Street 1:1700 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3022
Practice Address - Country:US
Practice Address - Phone:405-844-4300
Practice Address - Fax:405-844-4333
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN