Basic Information
Provider Information | |||||||||
NPI: | 1447546783 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WANDLING | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6431 FANNIN STREET | ||||||||
Address2: | SUITE MSB 4.020 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770305389 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7135007200 | ||||||||
FaxNumber: | 7134860971 | ||||||||
Practice Location | |||||||||
Address1: | 6411 FANNIN ST | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 77030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7135007200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2011 | ||||||||
LastUpdateDate: | 06/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 125060444 | IL | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0127X | R7923 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.