Provider Demographics
NPI:1700021227
Name:WANGMED
Entity Type:Organization
Organization Name:WANGMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:YU-WAH
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-455-7409
Mailing Address - Street 1:10845 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1717
Mailing Address - Country:US
Mailing Address - Phone:410-335-0008
Mailing Address - Fax:410-335-1133
Practice Address - Street 1:7802 EARLY MORNING ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2518
Practice Address - Country:US
Practice Address - Phone:410-335-0008
Practice Address - Fax:410-335-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD155274OtherMEDICARE
DCP424OtherCAREFIRST
MDDW1WBYOtherCAREFIRST
MD417555700OtherMEDICAL ASSISTANCE
GADP0510OtherRAILROAD MEDICARE