=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164688099
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN EDWARD ONG DYHIANTO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6912 FM 1488 RD SUITE A
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-356-1945
-----------------------------------------------------
Fax | 281-356-1978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6912 FM 1488 RD SUITE A
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-356-1945
-----------------------------------------------------
Fax | 281-356-1978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N3626
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------