Provider Demographics
NPI:1740369354
Name:WONG, KENDALL H (MD)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:H
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601A GOLDER AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4412
Mailing Address - Country:US
Mailing Address - Phone:432-332-2538
Mailing Address - Fax:432-332-2591
Practice Address - Street 1:601A GOLDER AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4412
Practice Address - Country:US
Practice Address - Phone:432-332-2538
Practice Address - Fax:432-332-2591
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138749008Medicaid
G51152Medicare UPIN