Provider Demographics
NPI:1326195892
Name:WANG, LI WEN (OD)
Entity Type:Individual
Prefix:DR
First Name:LI
Middle Name:WEN
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4619 PEACH GROVE RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-3107
Mailing Address - Country:US
Mailing Address - Phone:512-912-1165
Mailing Address - Fax:512-912-0525
Practice Address - Street 1:500 E BEN WHITE BLVD
Practice Address - Street 2:STE D - 600
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7470
Practice Address - Country:US
Practice Address - Phone:512-912-1165
Practice Address - Fax:512-912-0525
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4362TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU09916Medicare UPIN
TX00E02ZMedicare ID - Type Unspecified