Basic Information
| Provider Information | |||||||||
| NPI: | 1063516409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | OLIVER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 N MAR VISTA AVE APT 4 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911065314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188485583 | ||||||||
| FaxNumber: | 8188481872 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 W OLIVE AVE | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188485583 | ||||||||
| FaxNumber: | 8188481872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E4275 | CA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | E4275 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.