Provider Demographics
NPI:1093779282
Name:WANG, EDWIN YEN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:YEN
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 1:698 12TH ST SE STE 145
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4076
Mailing Address - Country:US
Mailing Address - Phone:503-588-2674
Mailing Address - Fax:503-391-1200
Practice Address - Street 1:698 12TH ST SE STE 145
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-588-2674
Practice Address - Fax:503-391-1200
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR277342085R0202X
NY2249152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241589Medicaid
139300Medicare PIN