Provider Demographics
NPI:1073856787
Name:WANG, ALICE (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 CLYO RD STE F
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2785
Mailing Address - Country:US
Mailing Address - Phone:937-208-5300
Mailing Address - Fax:937-208-5650
Practice Address - Street 1:6611 CLYO RD STE F
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2785
Practice Address - Country:US
Practice Address - Phone:937-208-5300
Practice Address - Fax:937-208-5650
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-01877208600000X
OH35.143080208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0455709Medicaid