Provider Demographics
NPI:1831297274
Name:WANG, DAVID (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-6262
Mailing Address - Fax:602-406-6261
Practice Address - Street 1:2910 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6261
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0920782084N0400X
AZ0079762084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092078Medicaid
IL130013716 - CA4079Medicare ID - Type UnspecifiedRR
ILL40007Medicare ID - Type UnspecifiedINDIVIDUAL #
IL846900Medicare ID - Type UnspecifiedGROUP #
ILL91922Medicare ID - Type UnspecifiedINDIVIDUAL #