Provider Demographics
NPI:1649217803
Name:WANG, LI JUAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LI JUAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY APC-12
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-2517
Mailing Address - Fax:401-444-8514
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY APC-12
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-2517
Practice Address - Fax:401-444-8514
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10437207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7009559Medicaid
RI007009559Medicare ID - Type UnspecifiedGROUP# 229006187
RIH56689Medicare UPIN
RI7009559Medicaid