Healthcare Provider Details

I. General information

NPI: 1508119157
Provider Name (Legal Business Name): STEWART WANG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N MOUNTAIN AVE SUITE 307
UPLAND CA
91786-5183
US

IV. Provider business mailing address

440 N MOUNTAIN AVE SUITE 307
UPLAND CA
91786-5183
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-6513
  • Fax:
Mailing address:
  • Phone: 909-985-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG85318
License Number StateCA

VIII. Authorized Official

Name: STEWART WANG
Title or Position: OWNER
Credential:
Phone: 909-985-6513