Provider Demographics
NPI:1770677262
Name:WANG, MARY GE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GE
Last Name:WANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4720 HORNBEAM DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1419
Mailing Address - Country:US
Mailing Address - Phone:301-924-0438
Mailing Address - Fax:202-865-1774
Practice Address - Street 1:4720 HORNBEAM DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20853-1419
Practice Address - Country:US
Practice Address - Phone:301-924-0438
Practice Address - Fax:202-865-1774
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00623171100000X
DCAC30026171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1970023OtherCIGNA, PPO
DCJ110-0001OtherCAREFIRST BLUECROSS BLUES
MD2370341OtherUH
MDBP21ACOtherCAREFIRST BLUECROSS BLUES
MD1006471OtherASH