Provider Demographics
NPI:1528225745
Name:WU, IAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:MICHAEL
Last Name:WU
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 1:76 CAMPANELLI INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1809
Mailing Address - Country:US
Mailing Address - Phone:508-587-0700
Mailing Address - Fax:508-587-0287
Practice Address - Street 1:76 CAMPANELLI INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-587-0700
Practice Address - Fax:508-587-0287
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261440207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022953390001Medicaid
MA110104356AMedicaid