Healthcare Provider Details

I. General information

NPI: 1275568958
Provider Name (Legal Business Name): GLORIA WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 BAILEY AVE
BUFFALO NY
14212-2008
US

IV. Provider business mailing address

1595 BAILEY AVE
BUFFALO NY
14212-2008
US

V. Phone/Fax

Practice location:
  • Phone: 716-893-8550
  • Fax: 716-893-4020
Mailing address:
  • Phone: 716-893-8550
  • Fax: 716-893-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number189620
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: