Healthcare Provider Details

I. General information

NPI: 1174599260
Provider Name (Legal Business Name): CHEN WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S 56TH ST STE 110
PHOENIX AZ
85034-2177
US

IV. Provider business mailing address

4909 N GLEN PARK PLACE RD
PEORIA IL
61614-4676
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-5211
  • Fax: 480-478-8091
Mailing address:
  • Phone: 309-674-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number036-114610
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number59198
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: