Provider Demographics
NPI:1528043882
Name:WANG, JIAN (MD)
Entity Type:Individual
Prefix:
First Name:JIAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 FAIRWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6525
Mailing Address - Country:US
Mailing Address - Phone:972-492-8880
Mailing Address - Fax:972-492-8818
Practice Address - Street 1:4100 FAIRWAY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6525
Practice Address - Country:US
Practice Address - Phone:972-492-8880
Practice Address - Fax:972-492-8818
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1075004-14Medicaid
TX84677FOtherBLUE CROSS BLUE SHIELD
TX1075004-14Medicaid
TX84677FOtherBLUE CROSS BLUE SHIELD