Provider Demographics
NPI:1760440531
Name:WONG, KIN S (DO)
Entity type:Individual
Prefix:
First Name:KIN
Middle Name:S
Last Name:WONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5120
Mailing Address - Country:US
Mailing Address - Phone:817-337-8884
Mailing Address - Fax:817-337-8075
Practice Address - Street 1:1921 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5120
Practice Address - Country:US
Practice Address - Phone:817-337-8884
Practice Address - Fax:817-337-8075
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9458207P00000X, 261QU0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149752106Medicaid
TX149752111Medicaid
TX149752104Medicaid
TX0063LSOtherBCBS
TXP00193257Medicare PIN
TXH56846Medicare UPIN
TX611121Medicare PIN
TX0063LSOtherBCBS
TX8B5869Medicare PIN