Healthcare Provider Details

I. General information

NPI: 1366981201
Provider Name (Legal Business Name): WELLSPRING PHYSICIAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHARLES EWING BLVD STE 160
EWING NJ
08628-3456
US

IV. Provider business mailing address

4359 ROANS CHAPEL RD
COLLEGE STATION TX
77845-4096
US

V. Phone/Fax

Practice location:
  • Phone: 855-673-2876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTOR K WONG
Title or Position: SVP - OPERATIONS
Credential:
Phone: 855-673-2876