Healthcare Provider Details

I. General information

NPI: 1851634786
Provider Name (Legal Business Name): SERENA KE JUN WANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SANTA MONICA BLVD SUITE 210
SANTA MONICA CA
90404-2023
US

IV. Provider business mailing address

2020 SANTA MONICA BLVD SUITE 210
SANTA MONICA CA
90404-2023
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-6200
  • Fax:
Mailing address:
  • Phone: 310-582-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA135917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: