Provider Demographics
NPI:1255313631
Name:WANG, JAMES (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-382-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0062660207L00000X, 207LP2900X
GA060334207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKK25OtherMEDICARE, GROUP NUMBER
GA444354919AMedicaid
GA444354919BMedicaid
MDP00224353OtherRR MEDICARE
MD407070400Medicaid
MDP00224353OtherRR MEDICARE
MD407070400Medicaid
MDI27553Medicare UPIN
GA444354919BMedicaid