Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | R5912 | TX |
N | 208200000X | Surgeon | R5912 | TX |
N | 208600000X | Surgeon | R5912 | TX |
NPI | 1225395833 |
---|---|
Provider Name | Jonathon Bryce-Edward Olenczak |
First Address | Houston, TX 77210-4439 |
Second Address | Houston, TX 77030-4009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2012 |
Last Update Date | 07/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
387485101 | (05) | TX |
387485102 | MEDICAID CSHCN (01) | TX |