Provider Demographics
NPI:1780724971
Name:WANG, FANG (MD)
Entity type:Individual
Prefix:DR
First Name:FANG
Middle Name:
Last Name:WANG
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 1:25 BRIARDALE PL
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-2700
Mailing Address - Country:US
Mailing Address - Phone:203-252-2463
Mailing Address - Fax:203-961-0064
Practice Address - Street 1:25 BRIARDALE PL
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-2700
Practice Address - Country:US
Practice Address - Phone:203-252-2463
Practice Address - Fax:203-724-9863
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001397620Medicaid
CT001397620Medicaid
CT080001666Medicare ID - Type Unspecified