Provider Demographics
NPI:1013206945
Name:WANG, YEN TUN (MD)
Entity Type:Individual
Prefix:
First Name:YEN
Middle Name:TUN
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:YEN TUN
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 470
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-242-6357
Mailing Address - Fax:818-242-3628
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 470
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-242-6357
Practice Address - Fax:818-242-3628
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123156207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA123156OtherMEDICAL LICENSE