Provider Demographics
NPI:1922111863
Name:WANG, MARILENE BETH (MD)
Entity Type:Individual
Prefix:
First Name:MARILENE
Middle Name:BETH
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE # 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-206-6688
Mailing Address - Fax:310-206-4105
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-206-6688
Practice Address - Fax:310-206-4105
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60942207YS0012X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G609420Medicaid
CA00G609420Medicaid
CAWG60942BMedicare PIN