Healthcare Provider Details

I. General information

NPI: 1003349697
Provider Name (Legal Business Name): WILSON CHING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 12/20/2021
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1919 W TAYLOR ST
CHICAGO IL
60612-7246
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 510-332-8023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA170572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: