=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194178202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YIFEI WANG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2016
-----------------------------------------------------
Last Update Date | 07/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 BROOKLINE AVE
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-650-9214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 BROOKLINE AVE UNIT 801
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-650-9214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number | 268703
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------