Healthcare Provider Details

I. General information

NPI: 1821416744
Provider Name (Legal Business Name): VIVIAN WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ SUITE 7501
LOS ANGELES CA
90095-7417
US

IV. Provider business mailing address

1131 N PACIFIC AVE
GLENDALE CA
91202-2358
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-7375
  • Fax:
Mailing address:
  • Phone: 310-825-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA141344
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: