Provider Demographics
NPI:1063455582
Name:WANG, PROSPER L (MD)
Entity Type:Individual
Prefix:DR
First Name:PROSPER
Middle Name:L
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:7600 SHAFFER PKWY
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-3004
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101089207Q00000X
CO51440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38609266Medicaid
CO022831OtherKAISER COMMERCIAL NUMBER
COCOA108781Medicare PIN
CO022831OtherKAISER COMMERCIAL NUMBER
ILL80362Medicare PIN