Provider Demographics
NPI:1295800548
Name:WANG, JONATHAN C (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
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 1:1335 LA PALMA ST UNIT G4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5267
Mailing Address - Country:US
Mailing Address - Phone:415-279-6685
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1112872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology