Basic Information
| Provider Information | |||||||||
| NPI: | 1023254273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | CHIA-CHI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SAYBROOK RD | ||||||||
| Address2: | S100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
| FaxNumber: | 8603474691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 253156 | NY | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | C2-0009849 | DE | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | 055725 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 03112190 | 05 | NY | MEDICAID |