Provider Demographics
NPI:1215556204
Name:WANG, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 HAMPSHIRE RD STE NO203
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2563
Mailing Address - Country:US
Mailing Address - Phone:424-217-9182
Mailing Address - Fax:
Practice Address - Street 1:42 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1347
Practice Address - Country:US
Practice Address - Phone:424-217-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351046778390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program