Healthcare Provider Details

I. General information

NPI: 1083369631
Provider Name (Legal Business Name): DANIEL WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVENUE 5TH FLOOR, ROOM 5-140
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-8147
  • Fax: 305-243-4650
Mailing address:
  • Phone: 305-243-8147
  • Fax: 305-243-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: