Basic Information
| Provider Information | |||||||||
| NPI: | 1073856787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6611 CLYO RD STE F | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372085300 | ||||||||
| FaxNumber: | 9372085650 | ||||||||
| Practice Location | |||||||||
| Address1: | 6611 CLYO RD STE F | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372085300 | ||||||||
| FaxNumber: | 9372085650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2020-01877 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35.143080 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0455709 | 05 | OH | MEDICAID |