Healthcare Provider Details

I. General information

NPI: 1407016579
Provider Name (Legal Business Name): YUAN WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MAR WALT DRIVE HOSPITALIST DEPARTMENT
FORT WALTON BEACH FL
32547-6796
US

IV. Provider business mailing address

1005 MAR WALT DRIVE HOSPITALIST DEPARTMENT
FORT WALTON BEACH FL
32547-6796
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-8100
  • Fax: 850-862-2303
Mailing address:
  • Phone: 850-863-8100
  • Fax: 850-862-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME114559
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: