Healthcare Provider Details

I. General information

NPI: 1235766759
Provider Name (Legal Business Name): SHUTAO WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HERRICK ST
BEVERLY MA
01915-1777
US

IV. Provider business mailing address

85 HERRICK ST
BEVERLY MA
01915-1777
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-3000
  • Fax:
Mailing address:
  • Phone: 978-922-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1016330
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: