Healthcare Provider Details

I. General information

NPI: 1225258338
Provider Name (Legal Business Name): JEFF G WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PUTNAM GRN
GREENWICH CT
06830-6877
US

IV. Provider business mailing address

123 W 79TH ST
NEW YORK NY
10024-6480
US

V. Phone/Fax

Practice location:
  • Phone: 203-774-9900
  • Fax:
Mailing address:
  • Phone: 212-750-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number50428
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number223458
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: