Healthcare Provider Details

I. General information

NPI: 1013008317
Provider Name (Legal Business Name): LOUIS WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SOUTH MAIN STREET SUITE 102
MIDDLETOWN CT
06457-3648
US

IV. Provider business mailing address

80 SOUTH MAIN STREET SUITE 102
MIDDLETOWN CT
06457-3648
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-1401
  • Fax: 860-347-1023
Mailing address:
  • Phone: 860-344-1401
  • Fax: 860-347-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number023241
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: