Provider Demographics
NPI:1457615395
Name:WANG, CHIACHIEN JAKE (MD)
Entity Type:Individual
Prefix:
First Name:CHIACHIEN
Middle Name:JAKE
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 1684
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71165-1684
Mailing Address - Country:US
Mailing Address - Phone:318-424-4088
Mailing Address - Fax:855-230-1466
Practice Address - Street 1:2600 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3950
Practice Address - Country:US
Practice Address - Phone:318-212-4639
Practice Address - Fax:318-212-8305
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
TXBP10047559390200000X
LA3049122085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program