=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538640669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES Y. WANG, MD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 S FIGUEROA ST STE 1050
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-5310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-684-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 S FIGUEROA ST STE 1050
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-5310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-684-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING OFFICER
-----------------------------------------------------
Name | GABRIELLE GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-684-4404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | A123156
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------