Provider Demographics
NPI:1821234378
Name:ONG, MENCHU DE GUZMAN
Entity Type:Individual
Prefix:
First Name:MENCHU
Middle Name:DE GUZMAN
Last Name:ONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-4557
Mailing Address - Fax:318-675-7662
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-4557
Practice Address - Fax:318-675-7662
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202630207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1356778Medicaid
4N584CW20Medicare PIN