Provider Demographics
NPI:1811211659
Name:DEJUN WANG M.D. INC
Entity Type:Organization
Organization Name:DEJUN WANG M.D. INC
Other - Org Name:DEJUN WANG M D INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-810-2983
Mailing Address - Street 1:18391 COLIMA RD
Mailing Address - Street 2:204
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2730
Mailing Address - Country:US
Mailing Address - Phone:626-810-2983
Mailing Address - Fax:626-810-5741
Practice Address - Street 1:19115 COLIMA RD UNIT 104
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-3074
Practice Address - Country:US
Practice Address - Phone:626-810-2983
Practice Address - Fax:626-810-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71575261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH29793Medicare UPIN