Provider Demographics
NPI:1124035324
Name:FANG, SUAT CHENG GO (MD)
Entity Type:Individual
Prefix:DR
First Name:SUAT CHENG
Middle Name:GO
Last Name:FANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 21ST ST STE C
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1012
Mailing Address - Country:US
Mailing Address - Phone:806-795-9326
Mailing Address - Fax:806-795-4835
Practice Address - Street 1:3804 21ST ST STE C
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1012
Practice Address - Country:US
Practice Address - Phone:806-795-9326
Practice Address - Fax:806-795-4835
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered302F00000XManaged Care OrganizationsExclusive Provider Organization
Not Answered302R00000XManaged Care OrganizationsHealth Maintenance Organization
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization
Not Answered305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00BK52OtherBLUE CROSS BLUE SHIELD ID
TX2315562OtherBLUE CROSS/ BLUE SHIELD
TX00BK52OtherBLUE CROSS BLUE SHIELD ID