Provider Demographics
NPI:1265545115
Name:OH, SANG WAN (MD)
Entity type:Individual
Prefix:MR
First Name:SANG
Middle Name:WAN
Last Name:OH
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 519
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30453
Mailing Address - Country:US
Mailing Address - Phone:912-557-4315
Mailing Address - Fax:912-557-3338
Practice Address - Street 1:257 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427
Practice Address - Country:US
Practice Address - Phone:912-557-4315
Practice Address - Fax:912-557-3338
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16117208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00012317AMedicaid
GA00012317AMedicaid