Healthcare Provider Details

I. General information

NPI: 1639186406
Provider Name (Legal Business Name): DAI-YUAN WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 W MAIN ST
RUSSELLVILLE AR
72801-2759
US

IV. Provider business mailing address

2205 W MAIN ST
RUSSELLVILLE AR
72801-2759
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-4311
  • Fax: 479-968-4399
Mailing address:
  • Phone: 479-968-4311
  • Fax: 479-968-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036112423
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number207229
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE-5291
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: