=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174517205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON K WANG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2005
-----------------------------------------------------
Last Update Date | 06/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MADRID BLVD 513
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-7968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-505-0974
-----------------------------------------------------
Fax | 941-637-9000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MADRID BLVD 513
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-7968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-505-0974
-----------------------------------------------------
Fax | 941-637-9000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0072508
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------