Healthcare Provider Details

I. General information

NPI: 1780171272
Provider Name (Legal Business Name): ELAINE WANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

IV. Provider business mailing address

3 CHESTNUT ST
ACTON MA
01720-4145
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5000
  • Fax:
Mailing address:
  • Phone: 978-760-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68686
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1016808
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: