Provider Demographics
NPI:1770656696
Name:WANG, JIN WEN (MD)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:WEN
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 1:10823 JEWEL AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4345
Mailing Address - Country:US
Mailing Address - Phone:718-896-4900
Mailing Address - Fax:
Practice Address - Street 1:10823 JEWEL AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4345
Practice Address - Country:US
Practice Address - Phone:718-896-4900
Practice Address - Fax:718-544-6209
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118085208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB79180Medicare UPIN