Healthcare Provider Details

I. General information

NPI: 1073550794
Provider Name (Legal Business Name): MICHAEL X WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: XIA WANG

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/23/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-1276
  • Fax:
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number2004035778
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2004035778
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: