Provider Demographics
NPI:1629333018
Name:WANG, JING GRACE (DO)
Entity Type:Individual
Prefix:DR
First Name:JING
Middle Name:GRACE
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SELWYN AVENUE
Mailing Address - Street 2:SUITE 1-C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 SELWYN AVE APT 1C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7628
Practice Address - Country:US
Practice Address - Phone:718-960-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014547208D00000X
NY00283075207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice