Provider Demographics
NPI:1356347512
Name:WONG, CARMEN P (MD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:P
Last Name:WONG
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 1:1140 WESTMONT DR
Mailing Address - Street 2:STE 520
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-4363
Mailing Address - Country:US
Mailing Address - Phone:281-457-1212
Mailing Address - Fax:281-457-1223
Practice Address - Street 1:1140 WESTMONT DR
Practice Address - Street 2:STE 520
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-4363
Practice Address - Country:US
Practice Address - Phone:281-457-1212
Practice Address - Fax:281-457-1223
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2015-11-05
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
TXJ3003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1477848877OtherGROUP NPI FOR TAX ID
TX0099HPOtherBCBS OF TEXAS
TX2487111OtherCIGNA PROVIDER NUMBER
TX2667722OtherAETNA PROVIDER ID
TX755597OtherHUMANA PROVIDER NUMBER
TX2487111OtherCIGNA PROVIDER NUMBER
TX00499FMedicare PIN