Healthcare Provider Details

I. General information

NPI: 1063516409
Provider Name (Legal Business Name): OLIVER WANG D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 W OLIVE AVE
BURBANK CA
91502-1825
US

IV. Provider business mailing address

268 N MAR VISTA AVE APT 4
PASADENA CA
91106-5314
US

V. Phone/Fax

Practice location:
  • Phone: 818-848-5583
  • Fax: 818-848-1872
Mailing address:
  • Phone: 818-848-5583
  • Fax: 818-848-1872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4275
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: