Healthcare Provider Details

I. General information

NPI: 1558511519
Provider Name (Legal Business Name): JOHN WANG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 NORTH FOURTH STREET
SPRINGFIELD IL
62794
US

IV. Provider business mailing address

520 NORTH FOURTH STREET
SPRINGFIELD IL
62794
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLP01289
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37762
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37762
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125060808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: