Provider Demographics
NPI:1447244363
Name:WANG, PENG NAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PENG
Middle Name:NAN
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:130 GREENTRAILS DR N
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2552
Mailing Address - Country:US
Mailing Address - Phone:314-469-1302
Mailing Address - Fax:314-275-8637
Practice Address - Street 1:2 MEMORIAL DR STE 103
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-259-5096
Practice Address - Fax:314-275-8637
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-052044207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD10052Medicare UPIN