Provider Demographics
NPI:1457336539
Name:WANG, JUN (MD)
Entity Type:Individual
Prefix:
First Name:JUN
Middle Name:
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:PO BOX 11535
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46859-1535
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:10351 DAWSONS CREEK BLVD
Practice Address - Street 2:STE D
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1904
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:260-969-0989
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01060887207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200850020Medicaid
OHH56883Medicare UPIN
IN200850020Medicaid