Provider Demographics
NPI:1164429585
Name:WANG, IDA (MD)
Entity Type:Individual
Prefix:
First Name:IDA
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 1:20 E HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3209
Mailing Address - Country:US
Mailing Address - Phone:626-447-8000
Mailing Address - Fax:626-447-8002
Practice Address - Street 1:20 E HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3209
Practice Address - Country:US
Practice Address - Phone:626-447-8000
Practice Address - Fax:626-447-8002
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A507350Medicaid
G15053Medicare UPIN
CA00A507350Medicaid