Healthcare Provider Details

I. General information

NPI: 1720003940
Provider Name (Legal Business Name): PAUL X WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PROSPECT AVE SUITE LD
HACKENSACK NJ
07601-2510
US

IV. Provider business mailing address

235 PROSPECT AVE SUITE LD
HACKENSACK NJ
07601-2510
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-4250
  • Fax: 201-343-7779
Mailing address:
  • Phone: 201-343-4250
  • Fax: 201-343-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA070019
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0063479
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: