Healthcare Provider Details

I. General information

NPI: 1083875728
Provider Name (Legal Business Name): ANNIE MISUNG WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR STREET
NEW HAVEN CT
06511
US

IV. Provider business mailing address

20 YORK STREET
NEW HAVEN CT
06511
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-5253
  • Fax: 203-785-3024
Mailing address:
  • Phone: 203-785-5253
  • Fax: 203-785-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number054116
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: