Provider Demographics
NPI:1659832251
Name:WAN, VIVIAN TY (DO)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:TY
Last Name:WAN
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 1:128 MOTT ST STE 501
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-5575
Mailing Address - Country:US
Mailing Address - Phone:212-587-8838
Mailing Address - Fax:
Practice Address - Street 1:128 MOTT ST STE 501
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5575
Practice Address - Country:US
Practice Address - Phone:212-587-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY322276207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program