Provider Demographics
NPI:1164607461
Name:WANG, TISHA SHIH-YUN (MD)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:SHIH-YUN
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE # 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-825-5316
Mailing Address - Fax:310-206-8622
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:SUITE # 365, 530, 420, 250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-206-6232
Practice Address - Fax:310-206-8622
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86107207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86107OtherMEDICAL LICENSE
CA00A861070Medicaid
CA1164607461OtherCCS PANELED
CA00A861070Medicaid
CAWA86107BMedicare PIN