Healthcare Provider Details

I. General information

NPI: 1013086859
Provider Name (Legal Business Name): LAWRENCE C WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SW WATER ST 1824
PEORIA IL
61602-1571
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 309-494-9320
  • Fax:
Mailing address:
  • Phone: 309-740-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-104660
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: