Provider Demographics
NPI:1780813139
Name:WISSINK, THEODORE FRANCIS (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:FRANCIS
Last Name:WISSINK
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 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:2727 W HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1669
Practice Address - Country:US
Practice Address - Phone:713-442-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ53032085R0202X, 2085R0202X
ORMD1667312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX355889201Medicaid
TX355889202Medicaid
TX355889202Medicaid
TX442183YKTXMedicare PIN
TX442183YKTUMedicare PIN