Provider Demographics
NPI:1003043274
Name:WAN, WILLIAM KWOK KUEN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KWOK KUEN
Last Name:WAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2262 S. WENTWORTH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616
Mailing Address - Country:US
Mailing Address - Phone:312-791-1013
Mailing Address - Fax:312-791-1444
Practice Address - Street 1:2262 S. WENTWORTH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-791-1013
Practice Address - Fax:312-791-1444
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19.15068122300000X
IL036.055709208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No122300000XDental ProvidersDentist