Provider Demographics
NPI: | 1669507588 |
---|---|
Name: | WANG, GEORGE C (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | GEORGE |
Middle Name: | C |
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: | PO BOX 586 |
Mailing Address - Street 2: | |
Mailing Address - City: | FLORHAM PARK |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07932-0586 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 973-671-1868 |
Mailing Address - Fax: | 973-358-6594 |
Practice Address - Street 1: | 16 POCONO RD STE 304 |
Practice Address - Street 2: | |
Practice Address - City: | DENVILLE |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07834-2908 |
Practice Address - Country: | US |
Practice Address - Phone: | 973-671-1868 |
Practice Address - Fax: | 973-671-1869 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-02-22 |
Last Update Date: | 2022-06-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 25MA07658700 | 207R00000X, 207RG0300X |
MD | D67789 | 207RG0300X |
NY | 282598 | 207RG0300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 018557400 | Medicaid | |
MD | 130519ZADO | Medicare PIN |