Provider Demographics
NPI:1134257058
Name:WANG, JEFFREY C (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5300
Mailing Address - Fax:323-442-6990
Practice Address - Street 1:1450 SAN PABLO ST STE 5400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5331
Practice Address - Country:US
Practice Address - Phone:323-442-5300
Practice Address - Fax:323-442-6990
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76303207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G763030Medicaid
CA00G763030Medicaid
CAWG76303AMedicare ID - Type UnspecifiedMEDICARE PPIN #