Basic Information
| Provider Information | |||||||||
| NPI: | 1497793509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILFONG | ||||||||
| FirstName: | LALAN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 8220 WALNUT HILL LN | ||||||||
| Address2: | SUITE 700, PROFESSIONAL BUILDING II | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752314427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147394175 | ||||||||
| FaxNumber: | 2149874161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | K5744 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | K5744 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 158076301 | 05 | TX | MEDICAID | 158076304 | 05 | TX | MEDICAID | 200235410A | 05 | OK | MEDICAID | 8R1590 | 01 | TX | BLUE CROSS OF TEXAS | OTHER | 158076302 | 05 | TX | MEDICAID |