Basic Information
Provider Information | |||||||||
NPI: | 1518908292 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WENDT | ||||||||
FirstName: | JULIET | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 201088 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 772161088 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7135003500 | ||||||||
FaxNumber: | 7135005484 | ||||||||
Practice Location | |||||||||
Address1: | 4812 SPRUCE ST | ||||||||
Address2: |   | ||||||||
City: | BELLAIRE | ||||||||
State: | TX | ||||||||
PostalCode: | 774014024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136608089 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 09/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | G5812 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 208000000X | G5812 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 125683607 | 05 | TX |   | MEDICAID | 125683616 | 05 | TX |   | MEDICAID | 125683617 | 05 | TX |   | MEDICAID | 125683618 | 05 | TX |   | MEDICAID | 125683606 | 05 | TX |   | MEDICAID | 8R0310 | 01 | TX | BCBS | OTHER |