Healthcare Provider Details

I. General information

NPI: 1588923023
Provider Name (Legal Business Name): XIAO BEN WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BEN WANG M.D.

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033
US

IV. Provider business mailing address

11175 CAMPUS ST STE A1117
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-5000
  • Fax:
Mailing address:
  • Phone: 909-558-4250
  • Fax: 909-558-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA129757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: