Provider Demographics
NPI:1457462921
Name:WANG, GUANG-JI (OD)
Entity Type:Individual
Prefix:
First Name:GUANG-JI
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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:617-350-7823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2223768OtherAETNA
MA6176OtherNEIGHBERHOOD
MA0391883Medicaid
MA99321901OtherNETWORK
MA9724630Medicaid
MAW20319OtherBLUE CROSS & BLUE SHIELD
MAW22016OtherBLUE CROSS & BLUE SHIELD
MA45722700001OtherCIGNA
MA762408OtherTUFTS
MA45722700001OtherCIGNA