Provider Demographics
NPI:1790927192
Name:WACKER, DOUGLASS JOHN (CPO)
Entity Type:Individual
Prefix:
First Name:DOUGLASS
Middle Name:JOHN
Last Name:WACKER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 LA BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-4046
Mailing Address - Country:US
Mailing Address - Phone:713-524-3949
Mailing Address - Fax:713-524-3915
Practice Address - Street 1:3900 LA BRANCH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-4046
Practice Address - Country:US
Practice Address - Phone:713-524-3949
Practice Address - Fax:713-524-3915
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO0012Medicaid
TX0210750001Medicare NSC