Healthcare Provider Details

I. General information

NPI: 1437610870
Provider Name (Legal Business Name): DR. DIANE WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE BLDG B
ATLANTA GA
30322-1200
US

IV. Provider business mailing address

1365 CLIFTON RD NE BLDG B
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2020
  • Fax:
Mailing address:
  • Phone: 404-778-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number32807
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number103295
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: