Provider Demographics
NPI:1346427846
Name:GUANG-JI WANG
Entity Type:Organization
Organization Name:GUANG-JI WANG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUANG-JI
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-321-6989
Mailing Address - Street 1:629 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3921
Mailing Address - Country:US
Mailing Address - Phone:781-321-6989
Mailing Address - Fax:
Practice Address - Street 1:629 MAIN ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-3921
Practice Address - Country:US
Practice Address - Phone:781-321-6989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU37463Medicare UPIN
MA4881440001Medicare NSC