Provider Demographics
NPI:1922120740
Name:WAMBLE, JOHN LEE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEE
Last Name:WAMBLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1600 JAMES BOWIE
Mailing Address - Street 2:SUITE D103
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-3340
Mailing Address - Country:US
Mailing Address - Phone:281-428-1870
Mailing Address - Fax:281-422-0658
Practice Address - Street 1:1600 JAMES BOWIE
Practice Address - Street 2:SUITE D103
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-3340
Practice Address - Country:US
Practice Address - Phone:281-428-1870
Practice Address - Fax:281-422-0658
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH69762084P0800X
MS060392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122256401Medicaid
TX00556JMedicare ID - Type Unspecified
E08979Medicare UPIN