Healthcare Provider Details

I. General information

NPI: 1194901132
Provider Name (Legal Business Name): STACI JOANN WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACI JOANN WELDON MD

II. Dates (important events)

Enumeration Date: 01/19/2008
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN 2ND FLOOR CARL'S CHILDREN'S HOSPITAL OF MI
DETROIT MI
48201-2119
US

IV. Provider business mailing address

4201 ST. ANTOINE UHC 5D MAILBOX# 226 UNIVERSITY PEDIATRICIANS
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5515
  • Fax: 313-745-5237
Mailing address:
  • Phone: 313-966-5051
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301090477
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: