Healthcare Provider Details

I. General information

NPI: 1043515877
Provider Name (Legal Business Name): HOLLY WANG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ALESSANDRO PL SUITE 200
PASADENA CA
91105-3149
US

IV. Provider business mailing address

PO BOX 50127
PASADENA CA
91115-0127
US

V. Phone/Fax

Practice location:
  • Phone: 626-696-1234
  • Fax: 626-696-1230
Mailing address:
  • Phone: 626-696-1234
  • Fax: 626-696-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA69635
License Number StateCA

VIII. Authorized Official

Name: EZEKIEL WANG
Title or Position: PRACTICE MANAGER
Credential:
Phone: 626-696-1234