Healthcare Provider Details

I. General information

NPI: 1578698874
Provider Name (Legal Business Name): ROBERT T. WANG, PH.D., M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 W OLYMPIC BLVD SUITE 301
LOS ANGELES CA
90036-4667
US

IV. Provider business mailing address

5901 W OLYMPIC BLVD SUITE 301
LOS ANGELES CA
90036-4667
US

V. Phone/Fax

Practice location:
  • Phone: 323-931-3100
  • Fax: 323-931-0030
Mailing address:
  • Phone: 323-931-3100
  • Fax: 323-931-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberG40989
License Number StateCA

VIII. Authorized Official

Name: ROBERT T. WANG
Title or Position: OWNER
Credential: PH.D., M.D.
Phone: 323-931-3100