Provider Demographics
NPI:1336220318
Name:WANG, JAW J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAW
Middle Name:J
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 1:101 E BEVERLY BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-726-1400
Mailing Address - Fax:323-726-2946
Practice Address - Street 1:101 E BEVERLY BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-726-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26671208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77724ZMedicaid