Healthcare Provider Details

I. General information

NPI: 1598085185
Provider Name (Legal Business Name): JUSTIN WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 FLOYD AVE APT #345
MODESTO CA
95355-8750
US

IV. Provider business mailing address

2929 FLOYD AVE APT #345
MODESTO CA
95355-8750
US

V. Phone/Fax

Practice location:
  • Phone: 650-823-1437
  • Fax:
Mailing address:
  • Phone: 650-823-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA124857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: