Healthcare Provider Details

I. General information

NPI: 1396778346
Provider Name (Legal Business Name): CHUNG NAN WANG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 LOMA VISTA RD SUITE B
VENTURA CA
93003-3101
US

IV. Provider business mailing address

6073 BRIDGEVIEW DR
VENTURA CA
93003-1131
US

V. Phone/Fax

Practice location:
  • Phone: 805-641-6434
  • Fax:
Mailing address:
  • Phone: 805-644-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA31187
License Number StateCA

VIII. Authorized Official

Name: CHUNG NAN WANG
Title or Position: PRESIDENT
Credential: MD
Phone: 805-642-8565