Provider Demographics
NPI:1083765861
Name:WANG, DANIEL LI-JEN (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LI-JEN
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 SWEET DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-5208
Mailing Address - Country:US
Mailing Address - Phone:925-283-3636
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTHLAND MALL
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2148
Practice Address - Country:US
Practice Address - Phone:510-887-2800
Practice Address - Fax:510-887-2812
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10603T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO106030Medicare ID - Type Unspecified