Provider Demographics
NPI:1982647434
Name:WANG, EMMA C (DO)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:C
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 LINCOLNWAY E
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-3501
Mailing Address - Country:US
Mailing Address - Phone:574-252-7133
Mailing Address - Fax:844-361-2090
Practice Address - Street 1:3006 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-3501
Practice Address - Country:US
Practice Address - Phone:574-252-7133
Practice Address - Fax:844-361-2090
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001493207Q00000X
IN002001493207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300037230Medicaid
IN000000386681OtherBCBS
IN000000386681OtherBCBS
INE90812Medicare UPIN