Provider Demographics
NPI:1447210786
Name:WANG, LAURENCE S (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:S
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 1:4705 MALONE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5481
Mailing Address - Country:US
Mailing Address - Phone:919-593-4688
Mailing Address - Fax:
Practice Address - Street 1:5245 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2209
Practice Address - Country:US
Practice Address - Phone:910-392-7806
Practice Address - Fax:910-392-2428
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126WRMedicaid
H05892Medicare UPIN
2027272Medicare ID - Type Unspecified