Healthcare Provider Details

I. General information

NPI: 1750678017
Provider Name (Legal Business Name): HONGTAO ALEX WANG M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALEX WANG M.D., PH.D.

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 E HERNDON AVE STE 103
FRESNO CA
93720-3164
US

IV. Provider business mailing address

1191 E HERNDON AVE STE 103
FRESNO CA
93720-3164
US

V. Phone/Fax

Practice location:
  • Phone: 559-794-2168
  • Fax: 559-272-1387
Mailing address:
  • Phone: 559-794-2168
  • Fax: 559-272-1387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.172476
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA168782
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number036.172476
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberR5678
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA168782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: