Provider Demographics
NPI:1396062311
Name:FANG, GWENDOLINE (MD)
Entity type:Individual
Prefix:MS
First Name:GWENDOLINE
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:567-307-7663
Mailing Address - Fax:
Practice Address - Street 1:715 RICHLAND MALL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3802
Practice Address - Country:US
Practice Address - Phone:567-307-7663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC163159207V00000X
OH35.137510207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0390792Medicaid
CA100478799Medicaid