Healthcare Provider Details

I. General information

NPI: 1942824271
Provider Name (Legal Business Name): JIWON LEE WANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/20/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 970
CHICAGO IL
60612-3828
US

IV. Provider business mailing address

1725 W HARRISON ST STE 970
CHICAGO IL
60612-3828
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7100
  • Fax:
Mailing address:
  • Phone: 312-942-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351046341
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.164733
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: