Healthcare Provider Details

I. General information

NPI: 1588628788
Provider Name (Legal Business Name): MICHAEL WAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 WARNER AVE SUITE 150B
FOUNTAIN VALLEY CA
92708-7510
US

IV. Provider business mailing address

11100 WARNER AVE SUITE 150B
FOUNTAIN VALLEY CA
92708-7510
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-6600
  • Fax: 714-546-6608
Mailing address:
  • Phone: 714-546-6600
  • Fax: 714-546-6608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA36431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: