Provider Demographics
NPI:1750678017
Name:WANG, HONGTAO ALEX (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:HONGTAO
Middle Name:ALEX
Last Name:WANG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:1191 E HERNDON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3164
Mailing Address - Country:US
Mailing Address - Phone:559-794-2168
Mailing Address - Fax:559-272-1387
Practice Address - Street 1:1191 E HERNDON AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3164
Practice Address - Country:US
Practice Address - Phone:559-794-2168
Practice Address - Fax:559-272-1387
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.172476208000000X, 2080P0206X
CAA168782208000000X, 2080P0206X, 2080P0206X
TXR56782080P0206X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX379470304Medicaid