Provider Demographics
NPI:1104981901
Name:WAYNE L. FENTON
Entity type:Organization
Organization Name:WAYNE L. FENTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS
Authorized Official - Phone:281-820-9393
Mailing Address - Street 1:350 N SAM HOUSTON PKWY E STE 255
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-3397
Mailing Address - Country:US
Mailing Address - Phone:281-820-9393
Mailing Address - Fax:281-820-9589
Practice Address - Street 1:350 N SAM HOUSTON PKWY E STE 255
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3397
Practice Address - Country:US
Practice Address - Phone:281-820-9393
Practice Address - Fax:281-820-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50063174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0951237OtherCIGNA
TX531372OtherBLUE CROSS BLUE SHIELD
TX3462357OtherAETNA
TX176613101Medicaid
TX531372OtherBLUE CROSS BLUE SHIELD
TX=========OtherHUMANA