Provider Demographics
NPI:1164576708
Name:WANG, KAIDONG (MD)
Entity Type:Individual
Prefix:
First Name:KAIDONG
Middle Name:
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 1:2664 SENTER RD
Mailing Address - Street 2:214
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-1171
Mailing Address - Country:US
Mailing Address - Phone:520-861-4363
Mailing Address - Fax:
Practice Address - Street 1:2664 SENTER RD
Practice Address - Street 2:214
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1171
Practice Address - Country:US
Practice Address - Phone:520-861-4363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54585208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65255Medicare ID - Type Unspecified
AZG69576Medicare UPIN