Provider Demographics
NPI:1386643260
Name:WANG, BO (MD)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 OHIO DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035
Mailing Address - Country:US
Mailing Address - Phone:972-731-7717
Mailing Address - Fax:972-731-7733
Practice Address - Street 1:4525 OHIO DRIVE
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035
Practice Address - Country:US
Practice Address - Phone:972-731-7717
Practice Address - Fax:972-731-7733
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092558809Medicaid
8C5870Medicare PIN
TX092558809Medicaid