Provider Demographics
NPI:1871789602
Name:LAM, BENNY WONG (DPM)
Entity type:Individual
Prefix:DR
First Name:BENNY
Middle Name:WONG
Last Name:LAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1702 KELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5627
Mailing Address - Country:US
Mailing Address - Phone:940-766-1292
Mailing Address - Fax:940-723-1650
Practice Address - Street 1:1702 KELL BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5627
Practice Address - Country:US
Practice Address - Phone:940-766-1292
Practice Address - Fax:940-723-1650
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0642213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018702302Medicaid
TXTXB111043Medicare PIN