Provider Demographics
NPI:1265574263
Name:1304 WONDER WORLD CENTER FOR CANCER CARE LTD
Entity type:Organization
Organization Name:1304 WONDER WORLD CENTER FOR CANCER CARE LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-396-2500
Mailing Address - Street 1:PO BOX 847506
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7506
Mailing Address - Country:US
Mailing Address - Phone:512-396-2500
Mailing Address - Fax:512-396-7640
Practice Address - Street 1:1304 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7532
Practice Address - Country:US
Practice Address - Phone:512-396-2500
Practice Address - Fax:512-396-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186352401Medicaid
TX00X421Medicare PIN