1457462921 NPI number — GUANG-JI WANG O.D.

Table of content: GUANG-JI WANG O.D. (NPI 1457462921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457462921 NPI number — GUANG-JI WANG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANG
Provider First Name:
GUANG-JI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457462921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
629 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALDEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02148-3921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02148-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-350-7823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3715 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2223768 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6176 . This is a "NEIGHBERHOOD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0391883 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99321901 . This is a "NETWORK" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9724630 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W20319 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W22016 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 45722700001 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 762408 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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