Provider Demographics
NPI:1851773881
Name:PANG, RUI WEN (MD)
Entity Type:Individual
Prefix:
First Name:RUI WEN
Middle Name:
Last Name:PANG
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 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-616-1445
Mailing Address - Fax:520-616-1446
Practice Address - Street 1:5224 W DOVE CENTRE RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-5063
Practice Address - Country:US
Practice Address - Phone:520-616-1445
Practice Address - Fax:520-616-1446
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR75316207R00000X
NC236665207RG0300X
AZ58715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ528748Medicaid