Provider Demographics
NPI:1053382051
Name:WANG, GARY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 MAIN ST
Mailing Address - Street 2:SUITE 210 SETON BLDG
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2693
Mailing Address - Country:US
Mailing Address - Phone:716-832-1000
Mailing Address - Fax:716-832-1001
Practice Address - Street 1:2121 MAIN ST
Practice Address - Street 2:SUITE 112
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2693
Practice Address - Country:US
Practice Address - Phone:716-832-1000
Practice Address - Fax:716-832-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216631-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02119762Medicaid
NYH28852Medicare UPIN