Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 28097 | TX |
N | 213EG0000X | General Practice | 28097 | TX |
Y | 1223P0106X | Oral and Maxillofacial Pathology | 28097 | TX |
NPI | 1417221169 |
---|---|
Provider Name | Kimberly Tong |
First Address | Jbsa Ft Sam Houston, TX 78234-4504 |
Second Address | Fort Sam Houston, TX 78234-4504 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2012 |
Last Update Date | 25/10/2019 |