Healthcare Provider Details

I. General information

NPI: 1063788255
Provider Name (Legal Business Name): ANGELA L.F. WANG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2012
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9939 MAGNOLIA AVE
RIVERSIDE CA
92503-3528
US

IV. Provider business mailing address

PO BOX 70180
RIVERSIDE CA
92513-0180
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-8802
  • Fax: 951-687-2250
Mailing address:
  • Phone: 951-354-3216
  • Fax: 951-848-9968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS13454
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A15739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: