Provider Demographics
NPI:1598924805
Name:WANG, WALLACE J (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
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 1:17 ELIZABETH ST
Mailing Address - Street 2:SUITE 608
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4803
Mailing Address - Country:US
Mailing Address - Phone:212-219-8031
Mailing Address - Fax:212-219-3903
Practice Address - Street 1:17 ELIZABETH ST
Practice Address - Street 2:SUITE 608
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4803
Practice Address - Country:US
Practice Address - Phone:212-219-8031
Practice Address - Fax:212-219-3903
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257569207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03267769Medicaid