Provider Demographics
NPI:1063476414
Name:WANG, WEN YI (MD)
Entity Type:Individual
Prefix:
First Name:WEN
Middle Name:YI
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 1:11614 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1748
Mailing Address - Country:US
Mailing Address - Phone:718-846-0606
Mailing Address - Fax:718-846-8684
Practice Address - Street 1:11614 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1748
Practice Address - Country:US
Practice Address - Phone:718-846-0606
Practice Address - Fax:718-846-8684
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196198-12085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1854517Medicaid
06584Medicare ID - Type Unspecified
NY1854517Medicaid