Healthcare Provider Details

I. General information

NPI: 1114128204
Provider Name (Legal Business Name): PETER S WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

101 E OLNEY AVE SUITE 400
PHILADELPHIA PA
19120-2421
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7890
  • Fax:
Mailing address:
  • Phone: 215-456-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD442315
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: