1063669471 NPI number — DR. WASYL WILLIAM FEDORIW MD

Table of content: LANI BOYUM PT (NPI 1013545276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063669471 NPI number — DR. WASYL WILLIAM FEDORIW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEDORIW
Provider First Name:
WASYL
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1063669471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77001-0207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-650-6900
Provider Business Mailing Address Fax Number:
888-355-5052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18885 KATY FWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77094-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-829-2000
Provider Business Practice Location Address Fax Number:
281-829-2220
Provider Enumeration Date:
08/27/2008

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: 207X00000X , with the licence number:  P4162 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 125050811 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 125050811 . This is a "ILLINOIS STATE LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P4162 . This is a "TEXAS MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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