Basic Information
| Provider Information | |||||||||
| NPI: | 1154353126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1869 | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917851869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099815882 | ||||||||
| FaxNumber: | 9093732828 | ||||||||
| Practice Location | |||||||||
| Address1: | 1317 W FOOTHILL BLVD | ||||||||
| Address2: | STE 148 | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917863676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099815882 | ||||||||
| FaxNumber: | 9099460833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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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 | 207RN0300X | A49349 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00A493490 | 05 | CA | MEDICAID |