Provider Demographics
NPI:1508119157
Name:STEWART WANG MD INC
Entity Type:Organization
Organization Name:STEWART WANG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-985-6513
Mailing Address - Street 1:440 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5183
Mailing Address - Country:US
Mailing Address - Phone:909-985-6513
Mailing Address - Fax:
Practice Address - Street 1:440 N MOUNTAIN AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5183
Practice Address - Country:US
Practice Address - Phone:909-985-6513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85318208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty