Provider Demographics
NPI:1750483632
Name:WANG, LORI AMY (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:AMY
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:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:2740 PROSPERITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4354
Practice Address - Country:US
Practice Address - Phone:877-511-4625
Practice Address - Fax:703-204-9006
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07938300174400000X
NY220095207RE0101X
VA0101268338207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI49853Medicare UPIN
NYA400086758Medicare PIN
NJI49853Medicare UPIN