Provider Demographics
NPI:1619357365
Name:WANG, BO (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
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 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 NW ELKS DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3745
Practice Address - Country:US
Practice Address - Phone:541-683-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263517207R00000X
OR203312207RH0003X
NY294546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY294546Medicaid