Basic Information
| Provider Information | |||||||||
| NPI: | 1154384352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3067 | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959923067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307514784 | ||||||||
| FaxNumber: | 5307514906 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 DEL NORTE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959914142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306748031 | ||||||||
| FaxNumber: | 5307514158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | L3866 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340020371 | 01 | TX | MEDICARE RAILROAD | OTHER | 8G4510 | 01 | TX | BLUECROSS/BLUESHIELD | OTHER | 10006843 | 01 | TX | AMERIGROUP | OTHER | 1527616-01 | 05 | TX | MEDICAID | 7430373 | 01 | TX | AETNA | OTHER |