Healthcare Provider Details

I. General information

NPI: 1043798077
Provider Name (Legal Business Name): SPINE & ORTHOPEDIC INSTITUTE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 N MACARTHUR BLVD STE 100
IRVING TX
75038-6497
US

IV. Provider business mailing address

18208 PRESTON RD D-9 #355
DALLAS TX
75252
US

V. Phone/Fax

Practice location:
  • Phone: 972-399-9012
  • Fax:
Mailing address:
  • Phone: 972-399-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberL9018
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberL9018
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberL9018
License Number StateTX

VIII. Authorized Official

Name: DR. DOUGLAS WON
Title or Position: SURGEON
Credential: MD
Phone: 972-399-9012