Healthcare Provider Details

I. General information

NPI: 1326186073
Provider Name (Legal Business Name): JONATHAN I WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W DUARTE ROAD G195
ARCADIA CA
91004
US

IV. Provider business mailing address

10151 YORK ROAD 120
COCKEYSVILLE MD
21030
US

V. Phone/Fax

Practice location:
  • Phone: 310-923-5362
  • Fax: 360-361-3400
Mailing address:
  • Phone: 888-481-9185
  • Fax: 888-481-9421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA75879
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA75879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: