Healthcare Provider Details

I. General information

NPI: 1689865289
Provider Name (Legal Business Name): FANG WANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 MEADOW RIDGE DR
PLANO TX
75093-3397
US

IV. Provider business mailing address

4625 MEADOW RIDGE DR
PLANO TX
75093-3397
US

V. Phone/Fax

Practice location:
  • Phone: 214-663-4029
  • Fax: 972-669-1313
Mailing address:
  • Phone: 214-663-4029
  • Fax: 972-669-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberL9540
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: