Healthcare Provider Details

I. General information

NPI: 1912223108
Provider Name (Legal Business Name): EUGENE WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

994 W JERICHO TPKE STE 104
SMITHTOWN NY
11787-3211
US

IV. Provider business mailing address

994 W JERICHO TPKE STE 104
SMITHTOWN NY
11787-3211
US

V. Phone/Fax

Practice location:
  • Phone: 631-543-1440
  • Fax:
Mailing address:
  • Phone: 631-543-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number259742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: