Healthcare Provider Details

I. General information

NPI: 1417184144
Provider Name (Legal Business Name): ANDREW C WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2009
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208B VFW PKWY SUITE 200
WEST ROXBURY MA
02132-4349
US

IV. Provider business mailing address

1208B VFW PKWY SUITE 200
WEST ROXBURY MA
02132-4349
US

V. Phone/Fax

Practice location:
  • Phone: 617-608-1575
  • Fax: 617-608-1576
Mailing address:
  • Phone: 617-608-1575
  • Fax: 617-608-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number256901
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number240628
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: