1003914151 NPI number — TIEN WONG M.D.

Table of content: MRS. JEA'N DEQUIA TERSHA WYATT LAPC, NCC (NPI 1447714258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003914151 NPI number — TIEN WONG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
TIEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003914151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6560 FANNIN ST
Provider Second Line Business Mailing Address:
STE 750
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030-2727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-524-3434
Provider Business Mailing Address Fax Number:
713-524-3220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6560 FANNIN ST
Provider Second Line Business Practice Location Address:
STE 750
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-524-3434
Provider Business Practice Location Address Fax Number:
713-524-3220
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  H3961 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207WX0107X , with the licence number: H3961 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4310136 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 80G068 . This is a "BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: E89756 . This is a "STERLING OPTION ONE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 101319501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1534421 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19422 . This is a "OPTICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: H3961 . This is a "UNICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10019568 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 101319502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26010 . This is a "SELECTCARE OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10019568 . This is a "AMERIVANTAGE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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