Provider Demographics
NPI:1356402093
Name:WANG, JIAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JIAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 WILLOW GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-3519
Mailing Address - Country:US
Mailing Address - Phone:832-766-3990
Mailing Address - Fax:
Practice Address - Street 1:151 KNOLLCROFT RD
Practice Address - Street 2:EXTENDED CARE LINE
Practice Address - City:LYONS
Practice Address - State:NJ
Practice Address - Zip Code:07019
Practice Address - Country:US
Practice Address - Phone:832-766-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08379000207QG0300X
TXM5568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK3204660Medicaid
TX186598202Medicaid
TX612739Medicare PIN
TX8K0677Medicare PIN
TXK3204660Medicaid
TXI71585Medicare UPIN