Basic Information
| Provider Information | |||||||||
| NPI: | 1255313631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
| FaxNumber: | 2293536060 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 18TH ST E | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293827120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | H0062660 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | H0062660 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 060334 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | KK25 | 01 | MD | MEDICARE, GROUP NUMBER | OTHER | 444354919A | 05 | GA | MEDICAID | 444354919B | 05 | GA | MEDICAID | P00224353 | 01 | MD | RR MEDICARE | OTHER | 407070400 | 05 | MD | MEDICAID |