Provider Demographics
NPI:1225463136
Name:COLBY WANG, MD, LLC
Entity Type:Organization
Organization Name:COLBY WANG, MD, LLC
Other - Org Name:PREVENTATIVE PSYCHIATRY
Other - Org Type:Other Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:COLBY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-886-6067
Mailing Address - Street 1:636 W REPUBLIC RD
Mailing Address - Street 2:B-112
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5818
Mailing Address - Country:US
Mailing Address - Phone:417-886-6067
Mailing Address - Fax:417-886-4035
Practice Address - Street 1:636 W REPUBLIC RD
Practice Address - Street 2:B-112
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5818
Practice Address - Country:US
Practice Address - Phone:417-886-6067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001009509261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO659312Medicare UPIN