Provider Demographics
NPI:1598983181
Name:WANG, ALICE WENTSUO (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:WENTSUO
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:8599 HAVEN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-919-7288
Practice Address - Street 1:8599 HAVEN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4849
Practice Address - Country:US
Practice Address - Phone:909-620-8180
Practice Address - Fax:909-919-7288
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA 1066832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1066830Medicaid
CA00A1066830Medicaid