Provider Demographics
NPI:1164614970
Name:WANG, CLIFFORD T (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:T
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 1:4401 W MEMORIAL ROAD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1722
Mailing Address - Country:US
Mailing Address - Phone:800-749-4560
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:4101 TORRANCE BLVD - EM DEPT
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-540-7676
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99611207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164614970Medicaid
CA00A996110Medicaid
CABX528WMedicare PIN
CA00A996110Medicare PIN
CABX528ZMedicare PIN