Provider Demographics
NPI:1073504643
Name:WANG, REGINA (MD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4720 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30071-5736
Mailing Address - Country:US
Mailing Address - Phone:770-934-7876
Mailing Address - Fax:678-990-7236
Practice Address - Street 1:2545 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3206
Practice Address - Country:US
Practice Address - Phone:770-934-7876
Practice Address - Fax:678-990-7236
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2019-11-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA050568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00951475BMedicaid
GA00951475AMedicaid
GAH55451Medicare UPIN
GA00951475AMedicaid