Provider Demographics
NPI:1750466264
Name:WANG, NANCY (OD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 AMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2470
Mailing Address - Country:US
Mailing Address - Phone:909-598-3878
Mailing Address - Fax:
Practice Address - Street 1:300 N EUCLID AVE STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6031
Practice Address - Country:US
Practice Address - Phone:909-982-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11233T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0112330Medicaid
CAOP11233Medicare ID - Type Unspecified
CASD0112330Medicaid
CAU81768Medicare UPIN