Provider Demographics
NPI:1508839481
Name:WANG, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
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 1:104 W 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9337
Mailing Address - Country:US
Mailing Address - Phone:309-799-7518
Mailing Address - Fax:309-799-3886
Practice Address - Street 1:104 W 18TH AVE
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9337
Practice Address - Country:US
Practice Address - Phone:309-799-7518
Practice Address - Fax:309-799-3886
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4255D7OtherJOHN DEERE NUMBER
IL91488OtherBLUE CROSS WELLMARK
IL60636OtherHEALTH ALLIANCE
IL143603OtherIHS
IL1508839481Medicaid
80096082OtherRR MEDICARE
IL2263301OtherPHCS
ILL99473Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
G41658Medicare UPIN
IL1508839481Medicaid
ID4255D7OtherJOHN DEERE NUMBER
IL143603OtherIHS