Provider Demographics
NPI:1861443079
Name:WANG, CHIH JEN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHIH JEN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:800-407-2696
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:1560 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1619
Practice Address - Country:US
Practice Address - Phone:618-397-6575
Practice Address - Fax:800-432-6004
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009615152W00000X
MO2004001752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009615Medicaid
ILP00403017OtherRR MEDICARE
ILU98228Medicare UPIN
ILK33670Medicare PIN
ILP00403017OtherRR MEDICARE
IL046009615Medicaid