=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124322052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONNY S. WANG, M.D. COLON AND RECTAL SURGERY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2011
-----------------------------------------------------
Last Update Date | 04/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 ENDEAVOR SUITE 306
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-387-7240
-----------------------------------------------------
Fax | 949-387-7219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 ENDEAVOR SUITE 306
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-387-7240
-----------------------------------------------------
Fax | 949-387-7219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SONNY SHENG-HUNG WANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-387-7240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | A81551
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------