Healthcare Provider Details

I. General information

NPI: 1093083701
Provider Name (Legal Business Name): BENJAMIN N. WAN, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 BUCKINGHAM WAY SUITE 500
SAN FRANCISCO CA
94132-1909
US

IV. Provider business mailing address

595 BUCKINGHAM WAY SUITE 500
SAN FRANCISCO CA
94132-1909
US

V. Phone/Fax

Practice location:
  • Phone: 415-665-6100
  • Fax: 415-665-6101
Mailing address:
  • Phone: 415-665-6100
  • Fax: 415-665-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92050
License Number StateCA

VIII. Authorized Official

Name: DR. BENJAMIN WAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 415-665-6100