Healthcare Provider Details

I. General information

NPI: 1073608543
Provider Name (Legal Business Name): WILSON WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 206
SAN RAFAEL CA
94903-5233
US

IV. Provider business mailing address

1601 18TH ST NW APT 601
WASHINGTON DC
20009-2516
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-8070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA75880
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number242920
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: