Healthcare Provider Details

I. General information

NPI: 1457428674
Provider Name (Legal Business Name): JIM C. WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STADIUM DR
MORGANTOWN WV
26506-7900
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4820
  • Fax: 304-293-6963
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA79074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: