Provider Demographics
NPI:1790743995
Name:WONG-DOMENECH, MARIA TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:TERESA
Last Name:WONG-DOMENECH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7502 OAK FERN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6888
Mailing Address - Country:US
Mailing Address - Phone:281-448-5437
Mailing Address - Fax:281-448-2988
Practice Address - Street 1:2925 W T C JESTER BLVD STE 4
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-7050
Practice Address - Country:US
Practice Address - Phone:281-448-5437
Practice Address - Fax:281-448-2988
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9030208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130879307Medicaid