Provider Demographics
NPI:1922730910
Name:ONG, EDILISA LU
Entity type:Individual
Prefix:
First Name:EDILISA
Middle Name:LU
Last Name:ONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 5TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-3362
Mailing Address - Country:US
Mailing Address - Phone:903-590-5000
Mailing Address - Fax:903-590-5005
Practice Address - Street 1:1000 E 5TH ST STE 400
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3362
Practice Address - Country:US
Practice Address - Phone:903-590-5000
Practice Address - Fax:903-590-5005
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV8715208000000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics