Healthcare Provider Details

I. General information

NPI: 1881072346
Provider Name (Legal Business Name): CANTY WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 270
SANTA MONICA CA
90404-2053
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-8585
  • Fax: 310-453-4844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA145356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: