Healthcare Provider Details

I. General information

NPI: 1821030065
Provider Name (Legal Business Name): MIRANDA O WANG-GOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11619 SHADOW CREEK PKWY # 110
PEARLAND TX
77584-7262
US

IV. Provider business mailing address

9235 KATY FWY STE 400
HOUSTON TX
77024-1507
US

V. Phone/Fax

Practice location:
  • Phone: 713-461-2915
  • Fax: 713-461-5307
Mailing address:
  • Phone: 713-461-2915
  • Fax: 713-461-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM3786
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: