Healthcare Provider Details

I. General information

NPI: 1922111863
Provider Name (Legal Business Name): MARILENE BETH WANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA #550
LOS ANGELES CA
90095
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE # 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6688
  • Fax: 310-206-4105
Mailing address:
  • Phone: 310-206-6688
  • Fax: 310-206-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG60942
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberG60942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: