Healthcare Provider Details

I. General information

NPI: 1699317883
Provider Name (Legal Business Name): XIAODONG WANG SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 09/05/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4844 186TH ST
FRESH MEADOWS NY
11365-1109
US

IV. Provider business mailing address

4844 186TH ST
FRESH MEADOWS NY
11365-1923
US

V. Phone/Fax

Practice location:
  • Phone: 718-869-3607
  • Fax:
Mailing address:
  • Phone: 718-869-3607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007337
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number031856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: