MEDICARE: MARY WANG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A102257	CA

General Provider Information

NPI Number	:	1053567842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WANG MD

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9333 GENESEE AVE STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-2113
Country	:	US
Telephone Number	:	858-657-8600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	02/16/2018

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