Provider Demographics
NPI:1992812390
Name:ONG, TIE S (MD)
Entity type:Individual
Prefix:DR
First Name:TIE
Middle Name:S
Last Name:ONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 THOMPSON AVE
Mailing Address - Street 2:P.O. BOX 506
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4557
Mailing Address - Country:US
Mailing Address - Phone:870-862-1577
Mailing Address - Fax:870-862-5916
Practice Address - Street 1:700 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4416
Practice Address - Country:US
Practice Address - Phone:870-862-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARR3031OtherST. MED.LICENSE #
AR5C070OtherGRP.'S MCARE PROV.#
ARR3031OtherST. MED.LICENSE #
AR53898C070Medicare PIN